Mood disorders refer to four primary classes of psychiatric illnesses: major depressive disorder (MDD), bipolar affective disorder, mood disorder due to a medical condition, and mood disorder due to substance abuse (American Psychiatric Association [APA], 2013). Mood disorders in children and adolescents have been associated with emotional and behavioral dysfunction (Lack & Green, 2009). Although mild daily variability in an individual's mood may be developmentally normal, sustained elevation or depressed mood over an extended period results in significant distress or impairment (APA, 2013). The accompanying behavioral and emotional impairment can result in problems with social, academic, and interpersonal functioning (Lack & Green, 2009).
Dysfunctional family environments, such as those caused by conflicts in the family, divorce, and poor parent–child interaction, can exacerbate behavioral and emotional impairment. Parent– child relational problems (PCRP) have been recognized as a risk factor for the progression, mediation, and moderation of childhood mental illnesses, including mood disorders (Wamboldt, Cordaro, & Clarke, 2015; Wamboldt, Kaslow, & Reiss, 2015). Despite there being many young individuals at risk, as suggested by a prevalence rate of 34% (n = 133) in a field trial (Wamboldt, Cordaro, et al., 2015), health care providers do not specifically screen for PCRP as a standard of care for children diagnosed with mental illnesses. In particular, although adolescents with mood disorders may improve over the course of a hospitalization, they are often readmitted for another episode of mood exacerbation, behavioral escalation, suicidal ideation, or self-harm behavior, which often may be associated with poor parent–child relationships. There is an opportunity to break this cycle of admission, discharge, and read-mission by screening and treating those with PCRP. Therefore, the objective of the current project was to implement a PCRP screening program in a metropolitan children's hospital in southeast Florida and refer those with PCRP for treatment.
A growing body of literature highlights the significance of genetic pre-dispositions and epigenetic factors (including environmental and family variables) in the development, facilitation, or moderation of mental illnesses (Caspi, Hariri, Holmes, Uher, & Moffitt, 2010; Copeland, Shanahan, Costello, & Angold, 2009; Uher et al., 2011). It has been noted that the risk for mental disorders can increase independent of genetic factors or with interaction of genetic factors and problems in family relationships (Wamboldt, Kaslow, et al., 2015). Such interactions have accounted for variations in antisocial symptoms in young individuals. In a study that evaluated conduct behavior problems in children and adolescents, Button, Scourfield, Martin, Purcell, and McGuffin (2005) concluded that genetic susceptibility to family dysfunction accounted for much of the variance in antisocial behavior in childhood and adolescence. According to Wamboldt, Cordaro, et al. (2015), children with this genetic disposition may be more challenging to parents. Other researchers note that parental conflict, hostility, or unresponsiveness may aggravate the child's behavioral difficulties (Davies & Cicchetti, 2014; Fearon et al., 2014; Leve et al., 2010; Samek et al., 2015).
The family systems perspective provides a framework for understanding factors associated with the development of internalizing symptoms, such as depression and anxiety. The framework conceptualizes the family as an interdependent collection of subsystems with family members belonging to multiple subsystems. The overall functioning and relationships between the subsystems contribute to everyone's well-being (Cox & Paley, 1997, 2003). In this context, family relationships are central to the development of internalizing symptoms. For example, in families characterized by conflict and harsh interactions, adolescents with depression experience exacerbation in depressive symptoms (Sheeber, Davis, Leve, Hops, & Tildesley, 2007). Family conflict is thought to peak during adolescence (Paikoff & Brooks-Gunn, 1991), and parent–child disagreements are more frequent and of greater intensity (Laursen & Collins, 1994). This increased frequency and intensity is expected because the developmental period of adolescence is also the time adolescents struggle with the challenges of peer pressure while seeking to detach from parental control (Luo, 2010).
Furthermore, behavioral and emotional impairment can be exacerbated in the setting of a dysfunctional family environment. Indeed, a less cohesive and more conflicted family environment has been associated with poorer societal competency and negative behavioral outcomes (Baum et al., 2007). Moreover, low mastery of family dynamics is thought to place children with temperament problems at greatest risk for internalizing and externalizing symptoms or behavior problems (Baum et al., 2007). Escalation in children's internalizing symptoms is associated with a decline in the quality of family relationships, and children develop internalizing symptoms at a faster rate as inter-parental relationship satisfaction declines (Brock & Kochanska, 2015).
However, high-quality parental relationships are thought to confer a protective effect on internalizing (e.g., depression, anxiety, low self-esteem) and externalizing (e.g., acting out, behavior problems), and are positively associated with child and family outcomes as measured by the child's social competence, school engagement, and parent–child communication (Moore, Kinghorn, & Bandy 2011). These observations are true in all sub-populations irrespective of ethnic, racial, socioeconomic, immigrant, and non-immigrant backgrounds. High-quality parental or happy relationships between cohabitating parents engender stable family life and confer protective benefits and positive child and family outcomes.
Given the beneficial effect of high-quality parental relationships, it is not difficult to envision why high-quality parent–child relationships would be beneficial to the mental health of adolescents. Studies have demonstrated that childhood behavioral problems can be improved by interventions that promote better fit parenting practices (Bor, Sanders, & Markie-Dadds, 2002). Furthermore, evidence exists that the quality of parent/caregiver–child relationships is important in modifying the outcome of interventions on childhood psychiatric and physical disorders. This evidence was demonstrated in studies that examined emotion-impacted outcomes for cognitive-behavioral therapy for adolescents with social anxiety disorder (Garcia-Lopez, Muela, Espinosa-Fernandez, & Diaz-Castela, 2009) and family-focused therapy for adolescents with bipolar disorder (Miklowitz et al., 2009). If the goal is to decrease childhood emotional and behavioral problems, the benefit of accurately identifying adolescents with dysfunctional family relationships, particularly PCRP, cannot be overemphasized and should be an important component of a holistic effort to address mental health needs of young individuals.
There is an opportunity to break the cycle of hospitalization, discharge, and readmission that may be caused by dysfunctional parent–child relationships by identifying adolescents with PCRP. Those with PCRP should be referred for holistic therapy/intervention that addresses the underlying cause of their PCRP. The anticipated long-term outcome is that screening and treating PCRP will result in an improved parent–child relationship, which may in turn reduce behavioral escalation after discharge, improve emotional and behavioral function, and reduce rehospitalization.
PCRP was described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a pattern of interaction between a parent and child, such as impaired communication, overprotection, or inadequate discipline, that is associated with the development of clinically significant symptoms in a child or parent, or associated with clinically significant impairment on individual or family functioning (APA, 1994; Wamboldt, Cordaro, et al., 2015). However, this definition lacks clarity and is insufficient for the diagnosis of PCRP. The Relational Processes Workgroup (ad hoc to the fifth edition of the DSM [DSM-5]) has now proposed more specific criteria along with a semi-structured PCRP questionnaire that can be used in the diagnosis of PCRP (Wamboldt & Cordaro, 2013; Wamboldt, Cordaro, et al., 2015).
Project Setting and Ethical Statement
Under the authority of the University of Miami Human Subjects Research Office, the current practice improvement project was deemed to have met the criteria of non-human subjects' research. The project was implemented at a 20-bed inpatient pediatric psychiatric unit in a metropolitan children's hospital in southeast Florida. With permission from Dr. Wamboldt, this project used a semi-structured questionnaire for assessing caregiver–child relationship problems (Wamboldt & Cordaro, 2013) and the diagnostic criteria proposed by the Relational Processes Workgroup (Wamboldt, Cordaro, et al., 2015) to screen for PCRP.
Procedure and Data Collection
Parents (or the patient's caregiver) and patients admitted to the unit were screened for PCRP within 24 hours of admission during the 2-week project implementation period. RNs who were trained on how to use the tool performed the screening. The primary population of interest was patients with mood disorders. However, to avoid missing an opportunity to conduct PCRP assessment before diagnosis, all adolescents (ages 10 to 17) presenting for admission during the project period were assessed with the PCRP tool. After the adolescent and parent/caregiver dyad completed the questionnaire, the assessment staff reviewed the responses and used the diagnostic criteria (Wamboldt, Cordaro, et al., 2015; Wamboldt & Cordaro, 2013) to determine whether PCRP was present. If present, the patient's problem list was to be updated within 24 hours to include PCRP. Similarly, within 72 hours of PCRP diagnosis, a PCRP-specific care plan was to be formulated. In addition, to measure the time burden on staff to use the tool, the time it took to (a) administer the tool, (b) review responses, and (c) use screening criteria to determine PCRP status was measured. Figure 1 depicts the full process of care.
Process of care.
Note. PCRP = parent–child relational problems.
Patient satisfaction with the PCRP assessment tool was also evaluated, and patients' intervention status prior to discharge was determined. For patients with PCRP, the status of therapy (i.e., whether therapy was initiated, completed, and/or outpatient referral made prior to discharge) was documented. In addition, parents were asked to rate their impression of the assessment tool using a Likert scale (from 1 = extremely dissatisfied to 10 = extremely satisfied). These data, along with the patient's age, gender, diagnosis, and PCRP status, were recorded and subsequently analyzed with GraphPad Prism version 7.
Assessment of Parent–Child Relational Problems
The Relational Processes Workgroup (ad hoc to DSM-5) proposed a set of criteria that define or guide recognition of PCRP (Wamboldt, Cordaro, et al., 2015; Wamboldt, Kaslow, et al., 2015). There are two sets of criteria for relational problems. Criteria A assess whether caregiver–child relationship dissatisfaction or distress occurs for a greater number of days than when it does not occur during the past month. Criteria B recognize developmental need and sociocultural context and assess if dissatisfaction is associated with disturbance in at least two major areas of functioning, including behavior, cognition, emotion, or health (Wamboldt & Cordaro, 2013). PCRP exists if one item of Criteria A and at least two items of Criteria B are satisfied.
The semi-structured parent–child relational questionnaire comprises constructs that assess behavioral problems, parental over- and under-involvement, and cognitive and affective symptoms (Wamboldt & Cordaro, 2013). Each dyad completed the assessment interview, which comprised a collection of semi-structured interview questions testing these constructs. Respondents' responses were coded as “1,” “2,” or “3,” representing “no,” “subthreshold,” or “present,” respectively. One score of “3” in Criteria A and at least two scores of “3” in Criteria B are required to satisfy the criteria for diagnosis of PCRP.
All adolescents ages 10 to 17 admitted during the project implementation period were to be included in the project but due to conflict between time of admission and availability of parent and/or screening staff, a total of 15 adolescents and their parents were screened. Four (27%) patients were male, 10 (67%) were female, and one (7%) was transgender (Figure 2). The four males were diagnosed with aggressive behavior/attention-deficit/hyperactivity disorder, impulse control disorder, MDD, and suicidal ideation. The 10 females were diagnosed with bipolar disorder not otherwise specified, MDD with psychotic features, MDD, and suicidal ideation (Figure 3). Eleven (73%) of 15 patients screened positive for PCRP (Figure 4).
(A) Age and (B) gender distribution of patients.
(A) Gender and parent–child relational problem (PCRP) status, (B) primary diagnosis and PCRP status, and (C) primary diagnosis and gender distribution.
Note. AB/ADHD = aggressive behavior/attention-deficit/hyperactivity disorder; BP NOS = bipolar disorder not otherwise specified; ICD = impulse control disorder; MDD = major depressive disorder; SI = suicidal ideation.
(A) Parent–child relational problem (PCRP) status, and (B) gender distribution of patients with PCRP.
Time Burden on Staff to Use the Tool. To evaluate the time required to use the PCRP screening tool, staff recorded the time it took the patient and parent/caregiver to complete the questionnaire. The time it took staff to review their responses and determine whether PCRP is present using the diagnostic criteria was added. It took 45 to 65 minutes of staff time per patient and it was noted that this assessment could be done as part of the biopsychosocial assessment that is routinely performed at admission. Furthermore, English language competence could be a factor in the length of time it took to administer the assessment. Despite the PCRP assessment tool creators' efforts to reduce its reading level requirement, some patients and families required explanation of concepts. For example, participants frequently sought further explanation on the meaning of “under-involvement,” “over-involvement,” “negative attributions,” “contempt,” and “apathy.”
Implementation of the PCRP Intervention
When PCRP was identified, it was intended for the patient's problem list to be updated within 24 hours of diagnosis with PCRP and for a PCRP care plan to be formulated within 72 hours of diagnosis. However, neither of these outcomes could be achieved because the electronic health record (EHR) did not list PCRP as an option. As a result, providers were unable to add it to the problem list. Likewise, the care plan library did not have the option to select a PCRP-specific care plan. The closest item in the system was “interruptive family processes,” which is not synonymous with PCRP. Interruptive family processes are focused on family dynamics centered on adult members of the family as opposed to PCRP's focus on the relationships between caregiving adult members of the family and their dependent minors. The PCRP option had to be created in the EHR.
The project aimed to ensure that patients with PCRP received PCRP intervention by verifying therapy status (which has five possibilities) at discharge:
Therapy initiated and completed prior to discharge.
Therapy initiated but not completed prior to discharge and continuing with outpatient referral.
Therapy not initiated but referral in place prior to discharge.
Therapy not initiated and no referral prior to discharge.
Data show that all patients, with or without PCRP, initiated and completed therapy prior to discharge. On further evaluation, it was apparent that usual care includes therapy at admission and discharge. Patients with PCRP may need more specific PCRP-focused therapy and for a longer duration than usual care.
To evaluate whether PCRP screening addressed the need of patients being surveyed, parents/caregivers were asked to rate the assessment questionnaire using a Likert scale (Sullivan & Artino, 2013) from 1 = extremely dissatisfied to 10 = extremely satisfied. The term of reference was to evaluate their impression of using the tool to assess their relationship with their child. All parents/caregivers rated the tool at least 8/10. In terms of whether the tool explored everything they consider important in their relationship with their child, all parents/caregivers indicated “yes.” This finding suggests that screening for PCRP could potentially increase patient satisfaction in the quality of care in a pediatric psychiatric unit.
The current project found that approximately three fourths of patients screened had PCRP. This percentage is high when compared to the 34% (n = 133) reported in a field trial (Wamboldt, Cordaro, et al., 2015). Although the small sample in the current project could have contributed to the high percentage, it is also important to mention that the field trial (Wamboldt, Cordaro, et al., 2015) was conducted with patients in inpatient and outpatient settings. However, PCRP may be more common than originally thought. Reasons for poor PCRP can be complex and varied, including family's management of children's developmental stage of adolescence as they respond to peer influences and seek independence from parental control (Luo, 2010). In some cases, more deeply rooted issues are apparent, such as an adolescent's concern for parents' marital dynamics (Smith, 2016) or outright aversion of a parent. These complex scenarios require more than two family therapies given after admission and prior to discharge. As Smith (2016) noted, PCRP, such as those that are handled in parent–child reunification, require a well-thought plan for family-based therapy that addresses the underlying causes of the problems.
Although generic family therapy at admission and discharge may be good for all patients, those who screen positive for PCRP deserve more. As PCRP was present in 73% of the sampled population for this project, the problem may be more prevalent than originally thought. During multiple group therapy sessions conducted prior to the current project, a common theme that emerged from patients verbalizing their feelings and provocation for behavioral escalation, self-harm behavior, suicidal ideation, or mood exacerbation was the state of their relationship with their parents. Four in 10 adolescents in this therapy identified their relationships with their parents as the main cause of their mood exacerbation, behavioral escalation, suicidal ideation, or self-harm behaviors, and the reason they were often rehospitalized. Therefore, success with breaking the cycle of admission, hospitalization, discharge, and rehospitalization will require identifying those at risk.
Dysfunctional parent–child relationships do not provide a nurturing environment (Moore et al., 2011; Peterson & Zill, 1986). Consequently, many children live and grow under family variables that are noted as risk factors for the development, progression, mediation, or moderation of childhood mental health problems (Wamboldt, Cordaro, et al., 2015; Wamboldt, Kaslow, et al., 2015). Therefore, concerted effort to identify adolescents with PCRP using a PCRP assessment tool should be part of a comprehensive effort to provide mental health care to this population.
Although not assessed in the current project, the effect of staff buy-in in the success of a practice improvement project was incidentally perceived. On one occasion where the screener was available during the admission of a patient, the parent was not screened before leaving the unit. Staff buy-in has been recognized in the literature as essential for the implementation and sustenance of initiatives (French-Bravo & Crow, 2015) and the current project was no exception.
Nursing Implications and Future Directions
An important practice improvement issue is recognizing that PCRP is now a formal diagnosis. Nurses must acquire training on assessment, diagnosis, and treatment for PCRP. Nursing advocacy will facilitate integrating PCRP screening as a standard of care for young individuals with mental illness. There is a need to integrate PCRP in EHR libraries to facilitate the addition of PCRP in patients' problem lists as well as formulation of PCRP-specific care plans.
In the future, providers should be able to evaluate outcomes with respect to whether they have the necessary skills to provide holistic PCRP-focused therapy within the existing family therapy framework or whether it is necessary to hire new therapists with PCRP skills. Based on the multilingual nature of the patient population, instrument validation in other languages in addition to English is warranted.
The current project found PCRP was present in 73% of the sampled population. The resulting conclusions are limited by the small sample and other limitations. Nevertheless, PCRP may be more commonplace than originally thought. Additional studies with larger samples are warranted to determine the true prevalence of PCRP in the population. If and when validated, PCRP screening and development of appropriate interventions should be part of a holistic approach to ameliorating functional deterioration, disability, and cost associated with mental illness.
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