Elsevier

Child Abuse & Neglect

Volume 35, Issue 6, June 2011, Pages 448-458
Child Abuse & Neglect

Changes in parental depression symptoms during family preservation services,☆☆

https://doi.org/10.1016/j.chiabu.2011.02.005Get rights and content

Abstract

Objectives

Parental depression symptoms often change over the course of child welfare family preservation and parenting services. This raises the question of whether certain processes in family preservation services might be associated with depression symptom change. This study tests three correlational models of change among family preservation service participants: (a) changes in depression symptoms are one facet of broad general changes in wellbeing; (b) the quality of the home visitor-client relationship is associated depression symptom changes; and (c) linking parents to adjunctive services is associated with symptom changes.

Methods

Participants were 2,175 parents in family preservation services, largely for child neglect, who were surveyed using standard measures at pre-treatment, post-treatment and 6 month follow-up. Change patterns were evaluated using growth models, including bivariate parallel and multivariate second-order models.

Results

Parallel growth was noted among depression symptoms and changes in social, economic, familial, and parenting domains. A second order change model positing a global change pattern fit the data well. Working alliance had a modest association with improvement, but successful linkage to outside mental health services was not associated with improvement.

Conclusions

Changes in diverse indicators of wellbeing follow a global pattern which might support use of less complex rather than more fully comprehensive service plans. Findings about lack of adjunctive usual care mental health service benefit may be related to uncontrolled factors and this is a topic in need of additional study.

Introduction

One of the interesting observations from studies of parenting programs is that parental depression symptoms tend to change over the course of services even though these types of services do not include activities designed to function as depression treatment (Ammerman et al., 2009, Bagner and Eyberg, 2003, Chaffin et al., 2004, Ho, 2005, Sanders and McFarland, 2000). Family preservation and parenting programs are among the most common services provided to parents in child welfare (NSCAW Research Group, 2005). Providers in family preservation programs are home visitors, not mental health therapists. These services are not psychotherapy, but are focused on reducing family conflicts, improving parenting problems, increasing social support, helping families meet basic concrete and child care related needs, and brokering outside services. There is little research examining which if any of these service functions may be correlated with changes in depression symptoms.

Parents in the child welfare system commonly report depression symptoms, most often at mild-moderate levels, but sometimes severe. This has been observed across both physical abuse and neglect cases (Banyard et al., 2003, Berger, 2005). In a representative population sample, depression was identified as one of the stronger prospective risk factors for the initial onset of child maltreatment. Compared with non-depressed parents, depressed parents were around three times more likely to begin maltreating their children (Chaffin, Kelleher, & Hollenberg, 1996). A history of prior mental health problems, including depression, is also associated with child welfare recidivism (Drake, Jonson-Reid, & Sapokaite, 2006).

The mechanism(s) by which parenting services might impact depression symptoms are unclear and perhaps conjectural. The purpose of this study is to explore correlational patterns that might be predicted by three possibilities—one involving global life circumstance change, one involving characteristics of the home visitor-client relationship, and one involving the adjunctive service linkage function of these programs. The hypotheses are not intended to be exhaustive, to describe any model of depression treatment, nor to encompass any sufficient theory about depression, but do reflect three plausible patterns that might be potentially explain change during these types of services. Background for each is discussed in the sections that follow.

Hypothesis 1

Global change hypothesis

The first hypothesis is that changes in depression could be one facet of broad or global changes—a tide that lifts or lowers all boats. Under this hypothesis, changes seen among parenting or family preservation service targets (basic needs, social support, family conflict, parenting) and changes in depression symptoms would exhibit parallel growth trajectories. This hypothesis also would predict that a single global change dimension (i.e., a second-order latent slope) would provide a strong fit with the observed data in all of these areas, including depression symptoms. The areas apart from depression symptoms that will be examined in this study include the following, each of which will be discussed in terms of why it might show a parallel growth pattern with depression symptoms. The areas that will be examined are drawn from social, familial, parental, and economic domains, and none represents another internalizing mental health condition or construct with content that significantly overlaps depression symptoms (e.g., measures of distress or anxiety), although each has some precedent in the literature for association with depression symptoms.

Perhaps the dominant demographic characteristic of families in child welfare is poverty (Drake & Zuravin, 1998). Most families in child welfare live in poverty, sometimes extreme poverty. Poverty and low socioeconomic status also exhibit a stable relationship to depression over time in prospective epidemiologic data (Murphy et al., 1991). Difficulty meeting basic family and personal needs has been found to predict levels of depression, and mediates the relationship between lower income cultural group membership and depression symptoms (Plant & Sachs-Ericsson, 2004). Family preservation services attempt to improve sufficiency of basic needs. Assistance can take a number of forms, ranging from providing direct financial support, to linking families with basic needs programs, to helping families locate employment. It is possible that changes in how well basic concrete needs are being met parallels changes in depression symptoms.

Low social support is common among parents in child welfare, and is a factor in maltreatment recurrence risk (DePanfilis & Zuravin, 1999). Social support also is related to depression, particularly the lack of a confiding relationship (Leavy, 1983). In some home based family preservation models, developing social supports is a defining service philosophy (e.g., the Family Connections Model, see DePanfilis & Dubowitz, 2005). Family preservation providers often attempt to link parents to social networks, encourage parents to more actively engage these networks, and work to increase social capital, suggesting that parallel change might be observed between these two service targets.

Parents in child welfare may be engaged in high and chronic interpersonal conflict. This can include conflict with spouses, intimate partners, other family members, and persons outside the family. A substantial majority of all child welfare families report significant conflict in relationships, most often bilateral verbal aggression or violence (English et al., 2009). High levels of conflict and problems with others have been found to predict parental depression (Horwitz, Briggs-Gowan, Storfer-Isser, & Carter, 2007). One of the common goals of family preservation and support services is to mediate or reduce conflict using problem solving approaches. It is possible that changes in parental depression symptoms over the course of services parallels changes in the overall level of interpersonal conflict, both among family members and with others.

Depressed parents report a higher levels of parenting stress and problems with their children. To some extent, this can reflect a depressive perceptual bias toward children, but the relationship appears more complex than this and may involve bidirectional pathways (Friedlander, Weiss & Traylor, 1986) including pathways from child behavior problems to parental depression (Pelham et al., 1997). Parenting programs focused on improving child management skills often report concomitant reductions in both parenting stress and parental depression symptoms along with improvements in child behavior (e.g., Bagner and Eyberg, 2003, Sanders and McFarland, 2000). Parenting is perhaps the single most common element in child welfare service programs (NSCAW Research Group, 2005), and changes parenting problems may parallel changes in depression.

Hypothesis 2

Provider-client relationship

The second general hypothesis is that changes in depression symptoms are correlated with aspects of the parent-home visitor relationship. This includes the extent to which a strong working alliance is established, and the extent to which the home visitor is perceived as understanding the client and his or her cultural background. This is distinct from the general social support domain described above because it is a service process factor (a quality of the service itself) rather than an intended service target. Working alliance reflects a collaborative goal-oriented affiliation between the home-visitor and the parent. It includes agreement on goals, the steps needed to reach them, and a general feeling of liking and trust. Working alliance is a non-specific service characteristic that has been found to predict improvement across a wide variety of outcomes and service types. Although working alliance should not be construed as a treatment approach per se, it has been discussed as one aspect of so-called common factors in therapy, including effective services for depression symptoms (Barber et al., 1996, Casgonguay et al., 1996).

A strongly related aspect of the provider-client relationship is cultural competency. Cultural competency has been identified by federal government and professional organizations as a positive provider-client relational quality across mental health and social services (Sue, 2006). Cultural competency can exist at multiple service system levels, and have multiple facets. In this study we focus on the provider-client relationship dimension of cultural competency, including the client's perception of the provider's sensitivity to the clients values, respect for the family's beliefs and values, and how well the provider communicates in a way that is understandable to the client (Sue, 2006, Hernandez et al., 2009).

Hypothesis 3

Outside service linkage

The third hypothesis is that changes in depression symptoms are correlated with the adjunctive services to which home visitors may link parents. Family preservation home visitors are encouraged to identify significant mental health and other problems, know what adjunctive usual care services are available in their community, match clients to these services, and promote service engagement. It is possible that this linkage function is strongly associated with variations in depression symptom change, particularly among parents with significant levels of depression symptoms who are linked to mental health care. In this hypothesis, our intent is not to rigorously test any defined treatment, but simply to test the hypothesis that adjunctive usual care service linkage, broadly defined, will be correlated with change, especially among those with initially higher symptoms.

Section snippets

Participants

Participants in the study were 2,175 parents who were enrolled in a statewide network of home-based contracted family preservation and support programs operated by large non-profit community based agencies, 1 for each of the 6 child welfare administrative regions of the state. All participants were parents or caregivers referred by child welfare to the programs due to reports that they committed physical abuse and/or neglect of children in their household. Parents receiving services due to

Parallel growth models

Findings from the five parallel process growth models are shown in the separate columns of Table 1 for both the MAR and pattern-mixture approaches to missing data. In general, BDI intercepts correlated strongly with intercepts of the other variables, and the BDI change slope tended to be correlated with the other change slopes although statistical significance was not uniform across these relationships. Although not reported in the table, models without correlated residuals were tested and

Discussion

Among parents in home based child welfare services, depression symptoms were strongly correlated with problems and resources across a range of other common family preservation target areas, and changes in parental depression symptoms over the course of in-home family preservation services were found to parallel changes in these other areas. It is important to note that depression was the only mental health, internalizing or distress variable included in this intercorrelated nexus, and that the

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    This project was supported by grant number R01 MH065667 to Mark Chaffin from the National Institute for Mental Health. Additional in kind support was provided by the Violence Prevention Branch of the US Centers for Disease Control and Prevention.

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    The opinions expressed are those of the authors and do not necessarily reflect those of the NIMH or the CDC.

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