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Children of parents with mental illness (COPMI) are at greater risk of developing mental disorders themselves. Since impaired parenting skills appear to be a crucial factor, we developed a facilitated 8-session preventative group course called KopOpOuders (Chin Up, Parents) delivered via the Internet to Dutch parents with psychiatric problems. The goal was to promote children’s well-being by strengthening children’s protective factors via their parents. To reach parents at an early stage of their parenting difficulties, the course is easily accessible online. The course is delivered in a secure chat room, and participation is anonymous.
This paper reports on (1) the design and method of this online group course and (2) the results of a pilot study that assessed parenting skills, parental sense of competence, child well-being, and course satisfaction.
The pilot study had a pre/post design. Parenting skills were assessed using Laxness and Overreactivity subscales of the Parenting Scale (PS). Sense of parenting competence was measured with the Ouderlijke Opvattingen over Opvoeding (OOO) questionnaire, a Dutch scale assessing parental perceptions of parenting using the Feelings of Incompetence and Feelings of Competence subscales. Child well-being was assessed with the total problem score, Emotional Problems, and Hyperactivity subscales of the Strengths and Difficulties Questionnaire (SDQ). Paired samples
The sample comprised 48 parents with mental illness. The response rate was 100% (48/48) at pretest and 58% (28/48) at posttest. Significant improvements were found on PS Laxness and Overreactivity subscales (
This online group course on parenting skills is innovative in the field of e-support and among interventions for mentally ill parents. The pilot results are promising, showing moderate to large effects for parenting skills and parental sense of competence. Test scores at baseline indicating parenting problems were largely in the clinical range, and baseline scores indicating problems among the children were in the nonclinical range, suggesting that parents were reached at an early stage. Course satisfaction was high. Future research should focus on cost effectiveness and course adherence.
Parenting is a complex social skill, and it can be heavily undermined by mental illness [
The presence of risk factors in children of parents with mental illness is associated with an increased probability of onset of major health problems as well as greater severity or longer duration of these problems [
Parents with mental illness interact differently with their children than other parents. The parenting styles of mothers with unipolar depression, for instance, may be characterized by a flatter affect and less physical contact, lower levels of expressed approval or spontaneity, and more frequent anger [
In addition to the parents’ individual problems, there may be problem-related conflicts between parents, for instance conflicts about an alcoholic parent’s drinking. Parental stress and conflicts show associations with undue pressure and disapproval exerted on children [
A mental disorder in one parent can put growing pressure on the well partner. If the partner can meet the challenge, the consequences for the family and the children may remain limited [
From the point of view of mental illness prevention, protective factors are at least as important as risk factors. Protective factors are conditions that improve an individual’s resistance to risk factors and illness; they have been defined as “those factors that modify, ameliorate, or alter a person’s response to some environmental hazard that predisposes to a maladaptive outcome” [
If a parent and child have a good relationship despite the parental disorder, the child’s prognosis is significantly improved [
Strong support of the child by the unaffected parent may compensate for a deficit in support from the affected parent. In broader terms, a good relationship with at least one parent is a strong protective factor: a child can then cope with considerable difficulties without necessarily developing psychopathology. Social support from the unaffected parent, a sibling, or a support network or trusted person outside the family can help protect the child. Emotional and practical support are both important [
Realistic self-appraisal on the child’s part is crucial [
A clear understanding of the parent’s problems can be very helpful [
According to a study by Goodman and Brumley [
Parenting style can be improved by parenting support programs. Many studies have shown that preventive parenting support has positive effects on parents’ skills and sense of parental competence as well as on child well-being [
Evidence-based parenting programs for parents with mental disorders are less common [
According to a review by Fraser and colleagues [
Less intensive parenting support programs that are easily accessible and can reach parents at an early stage of parenting problems and children’s problems are not yet available for parents with mental illness. The preventative intervention KopOpOuders (Chin Up, Parents), an online group course, is intended to fill this gap. The advantages of an online group intervention for this target group are that it is anonymous (important because participants may feel shame or may fear losing custody of their children), requires no traveling time or babysitter, and enables contact with other parents in similar situations. KopOpOuders may also reach parents who are not in touch with mental health services.
The KopOpOuders intervention is an innovative intervention in several ways. Online group courses are still rare in the entire field of e-support. Only two online studies have been reported worldwide [
This paper describes the design and method of the online group course KopOpOuders and reports on the results of a pilot study that assessed parenting skills, parental sense of competence, child well-being, and course satisfaction.
The purpose of the KopOpOuders intervention for parents with mental illness is to enhance their children’s psychosocial well-being and to protect the children from developing mental health problems by improving their parents’ skills. We based KopOpOuders on recognized theories relevant to parenting support—social learning theory [
strengthening parent-child interaction
supporting the unaffected parent
ensuring a support network or trusted person for each child
reinforcing children’s coping and social skills
explaining the parental mental illness to the children.
Parent feels less guilt and shame about the mental illness and about the consequences for the home situation.
Parent knows what effects their own mental illness could have on the children.
Parent knows which protective factors exist for the child and is able to strengthen these.
Parent can articulate their own limitations and needs with respect to their parental role and can discuss these with a partner or trusted person.
Parent learns general parenting skills (eg, setting limits, dealing with conflicts), puts these into practice, and has a realistic idea of “good-enough parenting.”
Well parent feels less guilt and shame about the problems in the family.
Well parent knows how to keep functioning well and cope with the situation.
Well parent knows partner’s limitations and needs with respect to the parental role and can discuss these with the partner.
Well parent is able to support the partner in actively improving the partner’s parental role.
Parent knows his or her own support network and enlists its help when needed.
Parent allows children to seek support from others.
Parent has “emergency plan” in case of relapse.
Parent is familiar with services available to self, partner, and children and knows how to seek help there if needed.
Parent knows the children’s age-specific development tasks and gives them sufficient room to perform them.
Parent allows children to seek support from others.
Parent informs children in age-appropriate ways about the mental illness and absolves them of responsibility.
Parent gives children room to express their feelings.
Parent is familiar with available services for children and knows how to seek help from them if necessary.
Parent informs children in age-appropriate ways about the mental illness and absolves them of responsibility.
The KopOpOuders course is based on three mutually supportive principles. First, it facilitates the parents’ learning potential by highlighting and addressing their shame and guilt about their illness. Second, it teaches some general principles of parenting as well as more specific skills needed in the unique situation in which the parents and children find themselves. Third, the participants practice and consolidate this knowledge. Chat sessions, videos, and home exercises are provided to support participants as they put into practice parenting skills such as talking to children about psychological or addiction problems, listening to children, and setting limits. Consolidating the knowledge is facilitated by having participants record what they learn in a “plan of action” and fill in a “parenting atmosphere meter” every day.
The online course consisted of eight 90-minute weekly sessions in a secured chat room facilitated by one or two trained health promotion workers from four Dutch mental health organizations. (If the facilitator was highly experienced, one was sufficient.) Each course group had a maximum of six participants with mental illness. Between sessions, parents did homework and practiced parenting skills in structured home exercises. Participants were encouraged to invite their partners to read the session transcripts on the screen and to help carry out the homework exercises. The course focal points listed in
The chat room in which the course was delivered was part of the public website www.kopopouders.nl, which provided written information and videos about mental illness and parenting, a user forum, and an email service through which users could get individual support from a health promotion professional. The secured chat room screen had two parts: the left part was for chatting, and in the right part, the facilitator could post short videos to enhance recognition or other information such as the session agenda or an outline or diagram. The chat room screen included emoticons that participants could use to add a feeling to a message. To sign up for the course, participants completed online questionnaires. When accepted, participants received a log-in code. Registration was anonymous, but participants were asked to supply a mobile phone number to which an automatic text reminder could be sent half an hour before each weekly session.
From March 3, 2008, through May 13, 2009, 94 parents with mental illness, 88% of them female, enrolled in the KopOpOuders program. The parent's average age was 37 years with a range of 25 to 52 years (SD 6.8), and their children’s average age was 7.7 years, with a range of 1 to 21 years (SD 4.8). Accepted for the intervention were 85 parents with mental illness; 6 others did not respond further after completing the initial questionnaires, and 3 were excluded because of the longtime placement of the child out of the home, there were no parental psychological problems, or the children were over 21 years of age. Of those parents accepted, 26 withdrew before the course started citing reasons that included an unstable home situation (divorce, relocation, starting a rehabilitation, training, or reintegration program), postponement of participation, or no reason. Ultimately, 59 parents with mental illness began the intervention, 48 of whom gave informed consent to take part in the pilot study. The reasons that 11 parents failed to provide consent are unknown, but these parents were all female, 8 (73%) lived in single-parent families, 11 (73%) had intermediate or lower vocational education, and most reported that they experienced a mood disorder or a borderline personality disorder.
In the informed consent group (n = 48), 41 (85%) participants were female with a mean age of 37 years (SD 6.8); the mean age of their children was 6.7 years (SD 5.3). The following mental health problems were reported: depression or bipolar disorder (41%), personality disorder (38%), post-traumatic stress disorder (19%), attention-deficit/hyperactivity disorder (8%), anxiety disorders (6%), psychosis (6%), eating disorders (4%), alcohol addiction (4%), and autism (2%). Comorbidity was reported by 33% (16/48). Of the 48 participants, 28 (58%) lived in two-parent families or stepfamilies, 40 (83%) had one or two children, 27 (56%) were married, 43 (90%) were of Dutch ethnicity (the others were Belgian, Turkish, and Danish), 20 (42%) had intermediate and 13 (27%) higher vocational education, 25 (52%) had jobs or attended reintegration programs, and 45 (93%) had received professional psychological help from a mental health service. The partners of the mentally ill parents were not involved in the study.
Parents with mental health problems were recruited via the website, www.kopopouders.nl, or through recruitment materials distributed by four implementing mental health agencies, both internally, and to other mental health services in their regions. These included general practitioners, social services, and homecare services in four rural and urban regions in the Netherlands. Parents applied for the course via the website by completing questionnaires about their childrearing situation and the nature of the problems. Parents accepted for the course were also asked for their consent to take part in the study. Exclusion criteria for course acceptance were long-term placement of the children out of the home, severe personality or behavioral problems of children, the presence of acute crisis situations, and insufficient proficiency in Dutch.
At the start of the course (at pretest), parents completed questionnaires on parenting practices, child behavior, and sociodemographic background. The course comprised eight 1.5-hour sessions. At the end of the eighth session (posttest), participants completed questionnaires on course satisfaction, parenting practices, and child behavior.
To assess parenting practices, we used 12 questions from the Laxness and Overreactivity subscales of the Dutch version of the Parenting Scale (PS) [
Sense of parental competence was measured with a Dutch scale assessing parental perceptions of parenting: the Ouderlijke Opvattingen over Opvoeding questionnaire (OOO). The OOO has 11 questions that can be divided into two subscales: Feelings of Incompetence (6 items) and Feelings of Competence (5 items). Answers are rated on a 6-point scale with categories ranging from 1, “completely disagree” to 6, “completely agree.” The 6-item Incompetence scale of the OOO is a subscale taken from the Nijmegen Parenting Stress Index, short version [
The official Dutch 25-item Strengths and Difficulties Questionnaire (SDQ) [
A sociodemographic questionnaire gathered background data on the participants, such as family features, socioeconomic status, work status, number of children, problems within the family, and the motives for taking the course. An example item was, “What describes your family best?” The choices were: (1) regular family, that is, both parents are biological or adoptive parents; (2) stepfamily, that is, two parents one of whom is a stepparent; (3) single-parent family; (4) other.
Participants’ overall satisfaction with the intervention was measured at posttest on a 10-point scale using a custom-designed evaluation questionnaire in which 10 represented highly satisfied and 1 represented highly dissatisfied. Satisfaction was also evaluated through questions on course techniques, organization, and content. Example items were, “Did you encounter technical problems using the chat room?” “How satisfied are you with the content of session 1, session 2, and so on.” Items were rated from 1 to 10.
KopOpOuders is an innovative e-parenting support intervention designed for a specific group of parents. Though negative results were not expected, two-sided paired samples
The sample comprised 48 parents with mental illness who consented to study participation and took part in one or more course sessions. Response rate at pretest was 100% (48/48) and at posttest 58% (28/48). A logistic regression analyses with dropout at posttest as the dependent variable was executed. Participants who completed the course did not significantly differ from participants who dropped out of the study on any of the measured variables.
Short-term intervention effects on parenting skills, sense of parenting competence as measured by Ouderlijke Opvattingen over Opvoeding (parental beliefs about parenting-questionnaire) and child well-being as measured by the Strengths and Difficulties Questionnaire (n = 28)
At Pretest | At Posttest |
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Test and Subscale | Mean | SD | Scores in the Clinical Range |
Mean | SD | Scores in the Clinical Range |
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d | |
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Laxness | 3.41 | 1.08 | 75% | 2.85 | 0.79 | 43% | 2.90a | .007 | 0.52 | |
Overreactivity | 3.71 | 1.56 | 64% | 2.97 | 1.12 | 39% | 4.02a | .000 | 0.48 | |
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Feelings of incompetence | 26.32 | 5.62 | 22.88 | 5.01 | 3.13a | .004 | 0.61 | |||
Feelings of competence | 18.57 | 4.66 | 20.70 | 3.69 | 2.81a,b | .009 | 0.46 | |||
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Emotional problems | 4.36 | 3.08 | 36% | 3.75 | 2.61 | 32% | 1.57 | .13 | ||
Hyperactivity | 5.75 | 2.50 | 39% | 5.01 | 2.97 | 25% | 1.97 | .06 | ||
Total problems | 15.11 | 6.20 | 36% | 13.67 | 6.91 | 36% | 1.88 | .07 |
a
b The negative result is consistent with prediction and represents a positive change since parents feel more competent.
Results of the completers-only analyses are presented in
The course satisfaction questionnaire was completed by 27 parents at the end of the intervention. Their overall mean satisfaction rate was 7.8 on a 10-point scale. The highest-rated course topic was “giving better attention to your child” (mean score 8.0). Most parents indicated that the intervention had met their expectations well. The best-met expectation was “learning to deal better with feelings of shame, guilt, and incompetence,” which was cited by 100% (14/14), followed by “finding sympathy and recognition by sharing experiences,” cited by 73% (11/15) of parents. Satisfaction with the course facilitators was high: 78% (21/27) of parents found facilitators involved and supportive. A large majority of parents, 74% (20/27), considered the online intervention a better way to receive professional help than a face-to-face intervention. Most parents, 70% (19/27), responded that they would definitely recommend the intervention to other parents. Satisfaction was also expressed with the anonymity of the course, the opportunity to participate without leaving home, and the fact that no child care was needed. Most parents, 78% (21/27), were satisfied with the duration of the sessions, and 89% (24/27) with the interval between them; 52% (14/27), were satisfied with the number of sessions, but 44% (12/27) would have preferred more sessions. The course homework, including the practicing of parenting skills, was deemed fairly relevant to relevant by 100% (27/27) of the parents. Points for improvement were also suggested, with 41% (11/27) desiring more personal email contact with facilitators and a few participants wanting telephone or face-to-face contact. Some 30% (8/27) of parents expressed dissatisfaction with the number of dropouts from the course; others valued the greater personal attention in the smaller stay-behind groups.
Of the 59 parents who began the course, 42% (25/59) took part in fewer than four sessions, and 57% (34/59) in four sessions or more; 37% (22/59) attended seven or eight sessions, and 20% (12/59) all eight sessions. The reasons reported for dropping out during the course were varied, but often involved unstable home situations (eg, relational problems and divorce, relocation, or starting a reintegration program). As reported above, completers did not significantly differ from participants who dropped out of the study on any of the measured variables, indicating that loss-to-follow up was random.
At the onset of the study, many parents scored in the clinical range on parenting skills, indicating that they were facing serious childrearing problems. At the conclusion of the course, a large proportion of parents had moved out of the clinical range; the percentages of parents in clinical ranges for laxness and overreactivity at pretest (75% and 64%) had decreased by posttest to 43% and 39%, respectively.
Parenting skills of laxness and overreactivity (
In terms of children’s problems, the pilot results showed a decline, though not significant, on the SDQ scores. This contrasts with a significant finding for behavior problems from the Triple P level 4 program, which showed significant, moderate effects on the Eyberg Child Behavior Inventory (overall effect size
The fact that baseline parenting problems were largely in the clinical range and child problems in the nonclinical range suggests that parents were reached at an early stage of their parenting difficulties. The course satisfaction was high, with a mean score of 7.8 (10-point scale). The course adherence seemed to be a point for improvement and further research; 57% (34/59) followed half of the sessions or more, and only 20% (12/59) of the parents followed all the sessions. Finally, 93% (45/48) of the participants had received professional psychological help from a mental health service. This indicates a limited achievement of the aspiration to reach parents who had not been in contact with a mental health service. It is unknown, however, when these contacts took place; if this was long before the course attendance, the potential benefit of this online intervention might have been realized.
The most significant limitation of the study was the lack of a comparison group, making it impossible to conclude whether the significantly improved parenting competence was attributable to the course or to some other fact. The effect sizes from the trial may well have been inflated because they constituted the effects of spontaneous recovery and of nonspecific effects. It is thus likely that effect sizes in a well-controlled trial would be considerably smaller. A second limitation of this pilot study was the relatively small size. This precluded undertaking specific subanalyses, for example, to predict outcome from parent and child factors. A third limitation was the self-report nature of the quantitative parenting data. However, in keeping with the digital and anonymous nature of the intervention, independent observations were not feasible. Data on child behavior were based on reports of the parents rather than independent raters, and may have been biased. A final limitation was the lack of data from the period following the intervention so that it is not known whether the observed improvements continued, strengthened, or diminished in the longer term.
Future research on KopOpOuders will involve a controlled trial for measuring the effects of the intervention, including longer-term effects, on parenting and on child wellbeing. Cost-effectiveness analyses will be undertaken. The costs of the online course in terms of facilitator time are about the same as costs for face-to-face courses, but these costs are lower compared with costs of individual or family counselling. The expected short-term and long-term savings of online parenting courses lie in lower costs associated with work absenteeism and eventual treatment or care for parents and children.
Because the sample included a group of parents with mixed diagnoses, further analysis will examine diagnostic, symptom, and other variables that predict outcome. Future research should also target the role of the other partner or well partner and measure well-being. Finally, another area to explore is how the target group could be better reached.
Course adherence has been found to be associated with the success of a range of mental health programs [
In view of the increasing numbers of children now in care [
The anonymity of the course was valued by the parents. This anonymity, however, does not fit with the established procedures of many health insurance companies, which require that parents are identified. A new funding structure for online services that preserve anonymity is proposed in the Netherlands. The funding structure for online interventions is now brought to the attention of several stakeholders under the Dutch Ministry of Health. We think the anonymity may be of great importance. Such anonymity may lower the barriers to seeking help and might probably help to lower the risk of child abuse. According to the Netherlands Mental Health Survey and Incidence Study of 7076 Dutch people [
Our pilot study gives reason for cautious optimism about the prevention of mental health problems in a large at-risk group—children of parents with mental illness (COPMI). The objectives of the online intervention, KopOpOuders, appear to have been nearly achieved: reaching mentally ill parents at an early stage of their parenting difficulties and enhancing their children’s well-being by improving the parents’ childrearing competence.
Future research, with a randomized controlled design, should examine the short- and long-term effectiveness of this intervention on parenting, child well-being, and the well-being of the parents. Future research should also focus on cost-effectiveness of the intervention and on course adherence and the factors that can improve it.
KopOpOuders.nl was funded by the Achmea Eureka Foundation and the Rabobank Foundation
Karlijn Arntz and Rianne van der Zanden are the authors of the online group course, KopOpOuders.nl.
children of parents with mental illness
Diagnostic and Statistical Manual of Mental Disorders
Preventive Family Intervention
Ouderlijke Opvattingen over Opvoeding (parental perceptions of parenting questionnaire)
Parenting Scale
Strengths and Difficulties Questionnaire