Background
There is a growing need for inpatient hospital beds for young children requiring psychiatric care and a corresponding shortage of supply, with increased demand for hospitalization in the last decade [
1‐
3]. In addition, hospital readmission is frequent and the disorders young children suffer are often severe, requiring high use of psychotropic agents [
4,
5]. This paper describes the protocol of a feasibility trial with an intervention underway that aims to lessen the family burden of hospitalization of a young child, and to improve the quality of child-parent relationships.
It has been pointed out that compared with adolescents, younger children in psychiatric care tend to come from families with higher rates of psychosocial problems [
6]. There is ample evidence relating family factors to the onset of psychopathologic conditions and poor outcomes in children, especially parental psychopathologic conditions [
7‐
11]. Even if parents lose custody of their children during hospitalization or after discharge, most of them will continue having a relationship with them and maintain contact through visits [
12], and hopefully these children will in time return to their families as better conditions are achieved. Knowing this reality, one of the challenges when a child is hospitalized concerns how best to work with the family. This task is complicated by hospital settings (the majority) in which the psychiatric unit is not equipped to provide a bed for a parent to stay together with his/her child in hospital. This optimal pattern of hospital care, where parent and child stay together, would facilitate the delivery of dyadic treatment or family therapy. But when parents are not in the hospital, the offer of some form of family intervention is often not taken up, and when treatment begins, there is poor adherence or retention [
13].
In past decades, several attachment-based interventions have emerged, most often involving video-assisted therapy (see [
14] where 15 of 21 chapters about attachment-based interventions concern early childhood interventions, the vast majority including video feedback (VF)). VF has been shown to be an especially powerful tool in promoting change in parent–child relationships, often in just a few sessions [
15‐
20]. It seems that video helps parents to observe themselves from the outside and by replaying the video they can obtain a more realistic and adaptive perspective on the relationship they have with their children, and the direction in which they want to take the relationship [
18].
To the extent that seeing oneself on video is an emotional experience, it is likely that the experience, in part, activates the attachment system, calling for emotion regulation skills [
21] that a trained therapist can help the parent to achieve. Without adequate therapeutic support, parents who are shown a video of themselves with their children may feel alternately suspicious, fearful, shamed or exhausted.
This is why in the video-feedback intervention detailed below, which strongly relies on the approach of George Downing [
12], therapists are trained never to judge a parent, and to highlight the parent’s strengths and, especially, those of the child. In this way, the parent’s and child’s nascent-emotion regulation skills, and the child’s capacity to explore, are praised and nurtured. An emphasis is placed on all the good things that are evident in the parent-child interaction, but in addition to that, the therapist asks the parent whether, given the opportunity to go back in time to the moment of interaction shown on the video, would they do anything differently. A consistent theme in the therapeutic work is to focus repeatedly on the child’s development and what can help the child become (more) school-ready and competent at peer relations.
The intervention also aims to promote sensitive parental behavior, understood to be based on the parent’s mentalization skills. Mentalization is defined as the capacity to understand and interpret one’s own behavior and that of others as an expression of mental states such as feelings, thoughts, fantasies, beliefs and desires [
22]. This is based on research in parenting and child development that shows the importance of considering mental aspects underlying behavior in interactions between parents and children [
22,
23]. Interactions with primary caregivers who are sensitive and attuned to their needs provide infants with a sense of being held in a safe environment [
24], consistent with Bowlby’s definition of attachment [
25]. Reflective functioning (RF) is the operational definition of mentalization and was initially validated as a measure mentalization in the context of an Adult Attachment Interview, which is highly correlated with child attachment at 12 months [
14] (Fonagy P, Target M, Steele H, Steele M: Reflective-functioning manual version 5 for application to adult attachment interviews, unpublished).
Further evidence of the importance of mentalization or reflective functioning comes from studies showing that maternal sensitivity on its own is not enough to explain intergenerational transmission of secure attachment [
26], whereas parental mentalization has been shown to fill this transmission gap [
27‐
29]. Parental mentalizing is considered to have important implications for the development of self-regulation (Fonagy P, Target M, Steele H, Steele M: Reflective-functioning manual version 5 for application to adult attachment interviews, unpublished) [
28,
30].
The majority of research in VF has been conducted with babies or toddlers although several authors have also described the use of VF techniques with older children such as preschoolers and adolescents [
12,
31]. In a meta-analysis [
15], only 6 of the 29 studies included children over 5 years old and the majority were small trials without control groups.
There is evidence that parental reflective functioning (PRF) relates to social adjustment and emotional regulation in preadolescents and adolescents [
32,
33]. Therefore, improving PRF in the period of early childhood development could contribute to the promotion of better outcomes in young people. PRF might facilitate dialogue with children and foster a deeper understanding of their needs, thus contributing to their ability to face conflict and negative emotions appropriately [
32]. In the context of children in psychiatric care, increasing their parents’ PRF might promote the quality of their relationships, improve treatment results, and prevent future hospitalizations.
Children in inpatient psychiatric care frequently come from multi-problem families that require specific, brief, and effective interventions. The intervention proposed in the current study is designed to respond to this need. A randomized feasibility trial was designed in which subjects were randomized to a psychotherapeutic intervention that used video-feedback to improve PRF, during the hospitalization of children and early adolescents admitted to a psychiatric unit. The comparison group, who will not receive VF, will receive typical care and play sessions.
Due to the scarcity of research into the use of reflective functioning (RF) with parents of hospitalized children with severe psychopathologic conditions, a feasibility study was designed as a first step to conducting a future effectiveness study. A pilot study can also identify key factors in the design and implementation of evidence-based interventions that need to be tailored specifically to the context of public health services. In this sense, a feasibility study would allow for the detection of specific strategies for the use of new therapeutic tools with parents and their children in hospital.
Discussion
The study addresses an important gap in the knowledge on how to provide effective interventions for carers of children who are hospitalized in psychiatric units. As far as we know, children in need of inpatient psychiatric care come from multi-problem families in which most caregivers also suffer from mental disorders and in many cases do not receive any treatment [
6,
9]. Considering this context, a brief, effective, attractive and low-cost intervention is required. Video-feedback interventions primarily focus on caregivers’ resources and strengths, facilitating the establishment of rapport with participants and promoting their attendance. Not being criticized and feeling they can effectively take care of their children, can be a new and attractive experience for them that promotes self-efficacy as a parent. The end-of-treatment interviews with parents will explore the range of reactions parent will have had to the intervention.
Although these interventions can be beneficial when working with parents of children in psychiatric care, not all evidence-based interventions can be easily implemented in public psychiatric health services, for different reasons. Clinical teams might resist modifying the type of interventions they are accustomed to using, due to lack of training, difficulties in accessing the necessary training or concerns about the usefulness of the intervention in naturalistic settings. For these reasons, the stakeholders are being interviewed.
This pilot study seeks to demonstrate that it is feasible to develop an innovative, manualized and potentially effective intervention for multi-problem families who have their children hospitalized in a public psychiatric service. This pilot trial will inform how to conduct a future trial in order to assess the effectiveness of VIT in improving PRF, psychiatric symptomatology in children and parent-child interactions. Likewise, future research in this area can explore further the relationship between PRF and child psychopathologic conditions, and the specific role that video feedback may play in promoting PRF [
17] Additional file
1.
Acknowledgements
We would like to express our gratitude for the support and funding from the Innovation Fund for Competitiveness of the Ministry of Economy, Development, and Tourism, Millennium for Research in Depression and Personality Institute (Milenio para la Investigación en Depresión y Personalidad, MIDAP), Project IS130005 and the National Commission for Scientific and Technological Research, CONICYT Chile, the Fondecyt Initiation Project 11140230.