Background and rationale {6a}
Diagnosed in 10–15% of children worldwide, childhood mental illness [MI] remains a prominent public health concern [
1]. Childhood mental illnesses, including disruptive behavior disorders, attention-deficit/hyperactivity disorder, anxiety, and mood disorders, predict low quality of life akin to that of children with chronic physical health conditions [
2]. Early exposure to maternal depression is a notable risk factor for the development of childhood MI [
3,
4]. Maternal depression is most common in the first few years following childbirth [
5,
6]. Unfortunately, rates of clinically significant depressive symptoms among mothers doubled during the COVID-19 pandemic [
7]. Clinically significant depressive symptoms are now estimated to affect 26.9% of mothers worldwide [
7]. This increase suggests a current and critical need for interventions that concurrently address maternal depression and the prevention of childhood MI.
Rather than increasing risk for the development of any particular MI disorder or category, the intergenerational transmission of MI from mother to child is transdiagnostic and extends the risk broadly across many child psychopathology symptoms [
4]. Inherited genetic risk, innate dysfunctional neuroregulatory mechanisms, exposure to negative maternal cognitions, behaviors, and affect, and a more stressful childhood life context are theorized to contribute to the increased risk of psychopathology in offspring [
8]. Negative maternal cognition, behavior, and affect manifest in disrupted parenting practices among mothers with depression, including lower warmth and increased harshness [
9,
10]. Mothers with depression tend to engage in lower-quality interactions with their young children, characterized by decreased engagement and sensitivity, more irritability, and coercive or harsh discipline [
11]. Lower-quality parent–child interactions mediate the association between maternal depression and various deleterious childhood outcomes, including insecure attachment, increased risk of disruptive behavior disorders, and decreased executive functioning [
12‐
14]. Mothers facing additional stressors, such as living in poverty, may be at particular risk for persistent depression during their child’s life and may be more likely to exhibit negative affect while parenting (e.g., hostility, anger) [
11,
15]. Maternal depression is estimated to affect a quarter of mothers of young children globally, has deleterious effects on parenting practices, and increases the risk of child MI.
The COVID-19 pandemic led to both increased maternal depressive symptoms [
7] and an increase in child MI, including escalations in anxiety, depression, irritability, inattention, hyperactivity, and obsession/compulsion symptoms among Canadian children [
16]. Along with the threat of catching the virus itself, social and public health restrictions designed to mitigate transmission resulted in physical isolation from support and social networks, along with economic uncertainty and additional childcare responsibilities for parents. During the COVID-19 pandemic, families, and particularly mothers, were vulnerable to experiencing heightened parenting stress due to a sudden lack of family support and altered family relationships [
17]. Rates of child abuse and neglect also increased during the first year of the pandemic and parents with higher depressive symptoms were at greater risk of psychologically maltreating their children [
18,
19]. Restrictions related to COVID-19 have eased in many parts of the world; yet, it is unclear whether rates of maternal and child MI remain elevated. However, based on the established literature [
20], it is likely that increases in maternal depression during the pandemic will have cascading effects on the development of childhood MI.
There is an acute need to address maternal and child MI. Effective intervention strategies are necessary to simultaneously treat MI in mothers while preventing the development of MI in at-risk children [
21]. Several efficacious psychological treatments are available for treating depression in adults, including cognitive behavioral therapy and dialectical behavior therapy administered via group psychotherapy [
22,
23]. Group-based parenting programs teach parents skills to effectively manage difficult child behaviors and have been found to improve both parenting skills and child behavior problems [
24]. However, there are currently limited programs available that support maternal mental health while concurrently aiming to improve parenting, called dual-generation interventions [
3,
25]. Few programs have integrated interventions for both mothers and children, creating barriers (e.g., learning multiple therapeutic techniques) for mothers seeking support in both areas [
26]. Skills and knowledge acquired in programs targeting maternal MI are often non-transferable to parenting contexts, and vice versa [
27]. Emerging evidence has found that programs that simultaneously target maternal MI and parenting skills are up to 50% more effective than programs that target only one aspect [
25,
27]. These findings demonstrate the long-term value of dual-generation interventions to magnify the positive effects of parental interventions on child mental health outcomes [
3,
26‐
28].
In addition to increased efficacy, dual-generation programs may decrease barriers to participation for mothers of young children. Mothers attempting to access mental health and parenting interventions cite significant obstacles for engagement, such as requiring childcare, transportation, and time off work to attend programs [
29‐
31]. Due to barriers such as these, maternal depression is widely undertreated; in Canada, only one third of mothers with depression or anxiety report receiving treatment [
32]. By simultaneously treating depression and providing parenting support, barriers to participation in the intervention may be halved (e.g., requiring childcare once a week instead of twice).
To simultaneously address maternal and child MI, the
Building Regulation in Dual Generations (BRIDGE) group-based intervention was created. BRIDGE aims to increase intergenerational emotional regulation through pairing Dialectical Behavior Therapy (DBT) skills training with a theoretically aligned parenting skills program. DBT has been shown to be a propitious transdiagnostic treatment for underlying mechanisms of psychopathology, including emotion regulation difficulties common in depression, anxiety, and traumatic stress [
33,
34]. The integration of DBT with parenting programs is a promising approach for addressing intergenerational needs. Developmentally supportive parenting is facilitated by mothers own ability to effectively regulate emotions; in so doing, a mother can simultaneously manage her own internal emotional experience and limit over-reactivity towards their child, as well as teach their child about emotions [
26]. The aligned parenting content also includes best-practice behavior management training techniques, such as creating positive family routines and using positive reinforcement, framed within the context of DBT skills. BRIDGE holds promise to improve both maternal and child MI.
Two pilot studies have been conducted to evaluate BRIDGE [
35,
36]. In a pre-post feasibility study, mothers with depression (
n = 28) completed an in-person, 16-week trial of BRIDGE [
36]. The intervention demonstrated good feasibility, with high retention (86% retention) and significant reductions in maternal depression (
d = 1.02) and child MI (
d = 1.08). In focus groups conducted at post-test, participants indicated that they were generally satisfied with the program [
36]. Mothers expressed that they found the parenting skills complementary to the DBT skills, with one participant stating, “Because I understood the DBT language… it made it easier for me to understand it when we did it with children and the way it applies is just amazing.” In compliance with public health recommendations to reduce in-person contact and physical distance during the COVID-19 pandemic, a second pilot study was run to evaluate the efficacy of BRIDGE delivered via telehealth using asynchronous psychoeducational videos alongside synchronous weekly group sessions [
35]. Participants (
n = 39) showed significant reductions in child MI symptoms (
d = 0.41), maternal depression (
d = 1.13), and parenting stress
(d = 0.39) from pre- to post-intervention [
35]. Retention was high, with 92.3% of mothers completing the program [
35]. Given these favorable results, further research comparing BRIDGE to other available programs is necessary to expand services to mothers in need.
Objectives {7}
The current study will expand on previous evaluations of BRIDGE by conducting a randomized controlled trial (RCT) comparing (1) BRIDGE (DBT skills training + Parenting Skills), (2) DBT (DBT skills training only), and (3) services as usual (SAU). Our primary aim is to examine the effects of BRIDGE on maternal depression and child MI symptoms. We hypothesize that participants who receive the BRIDGE and DBT interventions will report fewer depressive symptoms than participants in the SAU group. Participants who receive the BRIDGE intervention are hypothesized to report fewer child MI symptoms than those in the DBT and SAU groups. Our secondary aim is to evaluate the efficacy of BRIDGE in reducing parenting stress and harsh parenting. Participants who receive the BRIDGE intervention are hypothesized to show lower levels of parenting stress and harsh parenting than those in the DBT and SAU groups.
Additional aims of the RCT are to examine the effects of BRIDGE and DBT on family relationships, other service use (e.g., hospital visits, interactions with police), and maternal psychopathology symptoms. We hypothesize that mothers who receive the BRIDGE or DBT intervention will report lower psychopathology symptoms, reduced service use, and improved family relationship quality. We will also assess participants' engagement in each intervention.
Exploratory outcomes of observed maternal sensitivity and child emotion regulation will also be examined via remote Zoom assessments. We hypothesize that mothers in the BRIDGE group will show greater maternal sensitivity and that their children will demonstrate improved emotional regulation, than those in the DBT or SAU groups. Additionally, we will invite participants’ co-parents to complete questionnaires on their own mental health and parenting. Furthermore, exploratory outcomes will include physiological indices of well-being (e.g., sleep and daily activity) measured via Fitbits that mothers will wear during the program. We hypothesize that participants who receive the BRIDGE or DBT interventions will display improved sleep quality and reduced sedentary behavior. Finally, we will also invite co-parents of enrolled participants to complete questionnaires related to their own MH and family relationships. Inviting co-parents to complete questionnaires during this trial is largely exploratory and will allow us to evaluate the feasibility of including assessments of co-parents in future trials. We hypothesize that some spill-over effects of the BRIDGE and DBT interventions may occur, such that co-parents of participants in either intervention group will show fewer MH symptoms and improved family relationship quality.
Trial design {8}
A three-armed, parallel-design RCT with repeated measures will be used to evaluate the efficacy of the 16-week telehealth BRIDGE intervention for mental health outcomes in mothers and their children aged 3–5 years old (at study enrolment) compared to a DBT-only and SAU control group. Participants will be randomly allocated, using central randomization stratified based on telehealth session availability and location, in a 1:1:1 ratio to BRIDGE, DBT, or SAU. Primary (depression and child MI), secondary (parenting stress and harsh parenting), and some exploratory outcomes (i.e., maternal psychopathology symptoms, family relationship quality, service use) outcomes will be assessed during the enrolment period (pre-test, T1), after the last week of the BRIDGE and DBT interventions (post-test, T2), and at follow-up (T3). Exploratory outcomes of maternal sensitivity and child emotional reactivity will be assessed at T1 and T2. Physiological data will be collected via Fitbits starting at T1 and continuing until T2. Co-parent’s mental health and parenting will be assessed at T1, T2, and T3.
This trial was registered with ClinicalTrials.gov (NCT05959538). The Research Ethics Board 1 at the University of Manitoba, Fort Garry campus, has reviewed and approved this study.