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Children of mentally ill parents at risk evaluation (COMPARE)

 

The BMBF (German ministry of education and research) funded study Children of mentally ill parents at risk evaluation (COMPARE) has three main goals:

 

1.    To evaluate the effectiveness of a parental prevention program to disrupt the transgenerational transmission of mental disorders

2.    To identify specific risk transmission mechanisms of mental disorders (e. g. emotion regulation)

3.    To test the model of the transgenerational transmission of mental disorders

 

Background

The German social report from the year 2013 reports a total of 19 million children/adolescents living in 1.6 million single and 8.1 million dual family households4. Given the estimated lifetime prevalence rate of 27.4 % for mental disorders associated with significant disability-adjusted life years (DALYs) for the age group 18-65 years5, approximately 25 % of the children/adolescents in Germany are living with a mentally ill parent, a percentage resembling international rates6–10. Having a parent with a mental illness has been associated with multiple psychological and developmental risks for children, such as lower academic achievement11, increased stress-related somatic health conditions (eg, higher rates of asthma and other atopic diseases12), internalizing/ externalizing symptoms13,14, and the development of severe mental illness (SMI)15. Our own study of n = 15.904 adult patients from 3 different psychiatric/psychosomatic clinics revealed that 65 % of the patients had children and that 73.4 % of those parents were currently caring for their children16. Of those children 15-38.4 % were exhibiting symptoms of mental disorders16, thus providing evidence that the trans-generational transmission of mental disorders (TTMD) is a major risk factor for the development of SMI, as demonstrated in numerous other studies15,17,18,13,19. Long-term studies have shown that children of parents with a mental illness (COPMI) have a higher life-time risk of developing SMI that ranges between 41 and 77 %; subclinical symptoms often present earlier, however17,18. The BELLA study revealed a parental mental illness as a powerful risk factor (OR 2.4) for the development of probable mental health problems in children and adolescents20. Recent studies have added evidence that offspring with two generations previously affected by SMI are at an even greater risk21,22. Thus, COPMI are most likely to constitute the next generation of patients with a mental illness15 associated with significant DALYs and economic costs23–25. They therefore constitute an essential target group to be addressed by selective (target high risk groups) prevention programs. Thus, to disrupt the insidious process of the trans-generational transmission of mental disorders26 is the first aim of our study (preventive intervention; P1).

 

Model of the transgenerational transmission of mental disorders (TTMD)

A recent meta-analysis of the trans-generational transmission of parental mental disorders on children’s symptomatology revealed specific effects of parental disorders on children15. According to this meta-analysis, both transgenerational concordance (specific parental mental disorders increase children’s risk for certain disorders) and multifinality (parental mental disorders increase children’s risk for mental disorders in general) are used to define the scope of the child’s diagnostic outcome/s of a particular parental disorder. The concepts of transgenerational specificity and equifinality refer, respectively, to differences and similarities in parental disorders preceding a child’s diagnostic outcome of different parental disorders. Multi- and equifinality appear to be more of a characteristic of children of parents with unipolar and bipolar affective disorders than of children of anxious parents, whose risk is mainly restricted to developing anxiety disorders. For all children, risk transmission is assumed to be partly specific since the studies indicate a strong tendency for children to develop the same disorder as their parent. A meta-analysis (k = 61) of the cross-sectional association between paternal and maternal psychopathology on children’s internalizing and externalizing behavior problems further revealed parent specific gender effects27.There is a general lack of studies on the specific risk transmissions for the broad range of parental disorders other than affective and anxiety disorders15. A comprehensive model (see figure 118) of the TTMD identifies four major domains (1. parent, 2. family, 3. child, 4. social environment) that interact with their respective systems and are influenced by five transmission mechanisms (1. genetics, 2. prenatal factors, 3. parent-child-interaction, 4. family and 5. social factors). Child development over its life span is considered, as are the concepts of multi- and equifinality, concordance, and specificity. While there is empirical support for the model’s different domains and factors, and factors, many have been studied in single dimensions (i. e. focussing on family or child factors or on genetics), but not as comprehensively as the model necessitates (for a review of the model components see16). Furthermore, most of those studies were conducted on individual disorders in parents, and comparative studies on the range of parental disorders and on crucial factors such as parental comorbidities are rare28 or entirely lacking15. Moreover, the specific impact of the various moderating and mediating processes between the incidence of mental disorders in parents and their children – such as genetics, epigenetics, stress reactivity, emotion regulation, parenting skills, parent-child-interaction, children’s cognitive abilities, family and environmental influences – as well as their interactions have not been clarified so far.

Thus, the second aim of our study is to test the TTMD model (model testing; P1-P8) and to simultaneously assess the four major domains as well as the five transmission mechanisms. This will enable us to establish specific transmission profiles (equi- vs. multifinality vs. concordance vs. specificity) for a range of parental disorders with/without comorbidities. Furthermore, we will be able to identify risk-profiles for children at high vs. low risk, since studies have shown that not all children will develop disorders themselves27 although their overall risk is significantly increased18. This will improve the development of targeted interventions, connecting our first aim with the second one, since the bi-directional influences of interventions on the TTMD as well as specifics of the TTMD on interventions have not been investigated so far.

 

Transgenerationale Transmission psychischer Störungen

Summing up, we expect that our approach, i. e. to simultaneously assess the domains and mechanisms of the TTMD model (model testing; P1-P8) as well as the bi-directional influences of a selective intervention (preventive intervention; P1) in one study, will substantially deepen our knowledge of the relevant transmission mechanisms and related child outcomes, as well as markedly improve children’s health. To reach this goal, we are proposing a Randomized Controlled Trial that: I) implements a preventive intervention and establishes effects of parental treatment on child outcome (P1); and II) tests the domains of the TTMD model within the RCT (P1) with sub-projects on emotion processing/regulation (P2), parent-infant-interaction (P3), stress reactivity (P4), (epi-)genetics (P5), atopic diseases (P6), parental work influences (P7), and academic and social outcomes (P8). To achieve the two major goals (preventive intervention, model testing), a highly competent interdisciplinary consortium with expertise in clinical child, adolescent and adult psychology and psychotherapy, developmental, educational, biological, work and organizational psychology, psychiatry, pediatrics, (epi-)genetics and biometrics/statistical methodology has been established. A prominent and unique feature of this consortium is that 5 research units incorporate therapeutic outpatient clinics for children/adolescents and adults. Thus, the assessment of parents with a mental illness and their children will be highly feasible and based on well-functioning existing structures. We realize that this topic is very complex, but believe that the established infrastructure of the participating centers as well as the COMPARE consortium’s expertise and the eight specific subprojects proposed will prove to be a highly feasible means of tackling this challenge.

 

 

References:

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The Impact of Various Parental Mental Disorders on Children's Diagnoses: A Systematic Review. Clinical child and family psychology review 2015; 18: 281–299. 16. Christiansen, H., Anding, J., & Donath, L. Interventionen für Kinder psychisch kranker Eltern. In: Michael Kölch, Ute Ziegenhain, Jörg M. Fegert (ed.) Kinder psychisch kranker Eltern.: Herausforderungen für eine interdisziplinäre Kooperation in Betreuung und Versorgung. Weinheim und Basel: Beltz Juventa, 2014, pp. 80–105. 17. Mattejat F and Remschmidt H. The children of mentally ill parents. Deutsches Ärzteblatt international 2008; 105: 413–418. 18. Hosman, C.M.H., van Doesum, K.T.M., & van Santvoort, F. Prevention of emotional problems and psychiatric risks in children of parents with a mental illness in the Netherlands: I. The scientific basis to a comprehensive approach. 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Zuletzt aktualisiert: 29.06.2018 · christih

 
 
 
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