Lynsey Gregg

Background Caring for children while experiencing psychosis can be difficult for parents, and their children risk poorer outcomes. Despite strong evidence for parenting interventions in the general population, it is not known if parents with psychosis find them acceptable or useful. This paper describes a study designed to investigate the feasibility and acceptability of conducting a randomised controlled trial (RCT) of an evidence-based parenting intervention for parents with psychosis in adult mental health services. Methods/Design In this two-arm rater-blind feasibility RCT of the self-directed version of the Triple P Positive Parenting Programme, participants will be allocated 2:1 to Triple P plus treatment as usual (TAU), or TAU alone. We will determine if we can recruit and retain 50 parents and assess if the intervention and study procedures are acceptable. A nested mixed methods process evaluation will also inform feasibility and acceptability. Self-report and observer-rated assessments will be conducted at baseline, 16 weeks post-randomisation and six and nine months post-randomisation to examine changes in clinical and economic outcomes including parenting stress, parental mental health, child behaviour, health-related quality of life and health status. Results Descriptive summaries will be produced for feasibility outcomes including consent, recruitment and retention rates; engagement with the intervention; outcome completion rate and number of adverse events. Randomised groups will be compared on clinical and economic outcomes using ANCOVA, adjusting for their baseline values and prognostic variables. Interview data will be analysed using framework analysis (care coordinators and parents) and interpretive phenomenological analysis (children). Discussion This is the first controlled trial to test feasibility, acceptability, uptake, retention, and potential efficacy of a parenting intervention for parents with psychosis. This study is essential to examine the contextual challenges involved in this setting with this population to optimise intervention delivery and study design for a future definitive full-scale RCT. Trial Registration Prospective ISRCTN registration (08/01/2024): ISRCTN 11847322; https://doi.org/10.1186/ISRCTN11847322

Objectives: Parental psychosis poses challenges for families but tailored support for parents remains limited. Very few studies have explored the day‐to‐day parenting practices of parents with psychosis in depth, and none have qualitatively compared their parenting to that of parents without serious mental illness (SMI). This study compared accounts from parents with psychosis to accounts from parents without SMI to explore parenting practices and identify areas for targeted support. Design and Methods: Semi‐structured qualitative interviews were used to explore the daily reality of child‐rearing in 20 parents with psychosis and 20 parents without serious mental illness. Data were analysed thematically using Template Analysis. Results: Three a priori themes were deductively generated from an established parenting model: Positive authoritative parenting , Negative authoritarian parenting and Permissive/avoidant parenting . Both groups of parents used positive parenting strategies well, but challenges such as stress and fatigue made it difficult for parents in both groups to maintain this approach consistently. Parents with psychosis were more likely to utilise authoritarian and permissive and avoidant parenting styles due to feeling overwhelmed, subsequently accompanied by feelings of guilt which may in turn, impact their mental health. Conclusions: The present study adds novel insights into how additional challenges such as positive symptoms and fatigue can affect the parenting behaviours of parents with psychosis resulting in greater use of maladaptive parenting practices. Evidence‐based parenting courses and utilisation of family‐focused approaches within services are recommended for families affected by parental psychosis to improve outcomes for parents and their children.

Parental psychosis has been reliably associated with adverse outcomes for both parents and children. Despite this, support for these families remains limited. Understanding the everyday parenting practices of parents with psychosis, and whether they differ from parents without psychosis is crucial for developing suitable, evidence-based interventions. We therefore aimed to synthesise quantitative and qualitative research to answer two research questions: (1) ‘What are the parenting practices of parents who experience psychosis?’ and (2) ‘Are the parenting practices of parents who experience psychosis the same as the parenting practices of parents without serious mental illness (SMI)?’ Five databases were searched for terms associated with parenting, psychosis and parenting practices, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The Mixed Methods Appraisal Tool was used for quality appraisal prior to an integrative narrative synthesis being conducted. Twelve studies (n = 9 quantitative; n = 3 qualitative) containing 1115 parents with psychosis were included. The synthesis revealed that parents with psychosis frequently use positive authoritative parenting strategies, but sometimes this can be difficult to sustain, with parents resorting to permissive and inconsistent parenting practices. They appear to do so more frequently than parents without SMI but because only four studies utilised a control group, more comparative research is needed. The review recommends further support, and use of parenting interventions for parents with psychosis, alongside systemic practice change initiatives within adult mental health services.

Introduction: A significant number of individuals with a serious mental illness (SMI) such as schizophrenia or bipolar disorder are also parents of dependent children. Despite the risk of adverse psychological, behavioral, and social outcomes their needs often go unmet. To better understand the needs of parents with SMI and their children it is necessary to gain insight into the perspectives and experiences of the professionals in adult mental health and children's services who work with them, and who, ultimately, are best placed to meet those needs.Aims: To explore the views and experiences of health and social care professionals working with parents with SMI to understand the needs of, and their role supporting, parents with SMI and their children.Methods: Semi-structured interviews were conducted with seventeen professionals from six NHS and Local Authority settings in England, UK. Participants were included if they were employed in adult mental health or local authority children's services and had experience of working with parents with SMI. Sampling was purposive, including a wide range of professions in these settings. Interview data were analyzed using template analysis taking a critical realist perspective.Results: Three top-level themes were generated: (1) Impact of parental SMI on the child, (2) Accessing support from services, (3) Role of professionals working with parents with SMI. Themes highlight diverse, wide-ranging effects of SMI on the child and a reluctance from parents to seek help due to stigma and fear. Available services are reported to be inaccessible and unacceptable to parents with SMI and practitioners experience conflict when balancing the needs of the parent and child. A whole-family approach facilitated by improved communication between services is advocated.Conclusion: Participants believed that parents with SMI experience complex parenting challenges over and above other parents, describing a largely detrimental impact on the child. Support services were deemed inadequate, and participants stressed the need to develop specialist services tailored toward the needs of parents with SMI and their children. Although participants endorsed joined up working across health and social care settings to facilitate a whole family approach, they required greater service knowledge and training in parental SMI.

Background: There is a significant risk of negative outcomes for families when a parent experiences serious mental illness. Family‐focused practice (FFP) emphasises the “whole family” as the unit of care and has been found to improve outcomes for service users and their families. Despite its benefits, FFP is not routinely implemented in UK adult mental health services. This study explores adult mental health practitioners' experiences and views of FFP within Early Intervention Psychosis Services in the UK. Methods: Sixteen adult mental health practitioners employed in three Early Intervention Psychosis teams in the Northwest of England were interviewed. Interview data were analysed using thematic analysis. Results: Five core themes were generated: (1) A limited understanding of FFP, (2) Our practitioners, (3) Our approach, (4) Our families and (5) Our services. Practitioners' understanding of FFP was limited and typically excluded dependent children. Practitioners' age, professional and personal experience, and preconceptions of families influenced delivery, and in turn, the engagement approach they adopted impacted families' responsiveness. The diversity and dynamics of service user families such as age, socioeconomic status, culture and stigma impacted FFP. An operational context characterised by insufficient resources reduced FFP; however, organisational structures such as leadership, clinical supervision and multi‐disciplinary teams facilitated FFP. Conclusions: FFP is not yet embedded within Early Intervention Services. Practice recommendations include agreeing on a formal definition of FFP and its scope; the development of FFP policy; clarity in relation to staff responsibilities and identities; the adoption of a collaborative approach which encourages service user choice and for time to be ring‐fenced to prioritise FFP. Future research should ascertain service user and family views on the facilitators and barriers to engaging with FFP in Early Intervention Services.

Objectives: Psychosis can present parents with complex parenting challenges and significant adverse outcomes for parents and their children have been reported. However, remarkably little is known about how parenting is experienced by these parents. Therefore, this qualitative study aimed to understand the lived experiences of parents with psychosis, including how parenting support was experienced. Design and Methods: Using interpretative phenomenological analysis (IPA), eight biological parents (five mothers and three fathers) with psychosis were recruited and interviewed from early intervention in psychosis services in the Northwest of England. Results: Three superordinate themes and seven subordinate themes were identified. Theme 1 ‘ Living with the Struggle: Painfully Disconnected’ captured a persistent parenting struggle that distanced parents from their children and support due to all‐consuming experiences of psychosis, fear and risk‐focused service support. Theme 2 ‘ Desired and Vulnerable Position: Comfortably Connected’ captured parental experiences of symptom relief through connection with their children, alongside parental need to be integrated with the systems around them. Theme 3 ‘Exposed: Parenting Under a Spotlight’ represented parental experiences of inescapable observation and judgement from the systems around them. Conclusions: Novel insights into the role of misaligned parent and service priorities in parental perceptions of powerlessness, shame and disconnection from their children, valued parenting identities, and system supports are presented. Systemic interventions that target stigma, provide system‐wide psychoeducation and promote person‐centred, compassionate and meaningful connections between parents and the systems they live within are needed to promote better parenting outcomes.

Parental mental illness is a major international public health concern given its implications for whole families, including children. Family-focused practice (FFP), an approach that emphasises a “whole-family” approach to care, provides an opportunity to mitigate the significant risks associated with parental mental health difficulties. The positive benefits associated with FFP have led to a shift in policy and practice towards prioritising FFP within adult mental health services. However, evidence suggests that FFP remains scarce and is not routine. Research has identified the important role of practitioners in facilitating FFP. The current review identified, synthesised and appraised the international qualitative literature examining adult mental health practitioners’ implementation experiences of FFP. It aimed to provide an evidence-informed account of practitioner experiences of FFP delivery and to identify key recommendations to enhance future FFP outcomes in AMHS. Ovid Medline, PsycInfo, CINAHL plus, EMBASE and Web of Science Core Collection were searched systematically, in line with PRISMA guidance, up to January 2022. The Critical Appraisal Skills Programme (CASP) was used to undertake the quality appraisal prior to a thematic synthesis being conducted. The review was registered on PROSPERO. Nineteen papers, spanning 17 years of research with 469 practitioners, were included. Three main themes and 14 subthemes were developed, representing different aspects of practitioner experiences of FFP delivery. Practitioners’ approach to FFP was variable and influenced by their beliefs about FFP, perceived roles and responsibilities, competence, service setting, and personal parenting status. Practitioners engaged in a balancing act to maintain a dual focus on their service-users and their children, to navigate powerful emotions, and consider multiple perspectives in a biomedical organisational structure that advocates individualised treatment. Although working together unified teams, a greater need for external interagency collaboration was identified. The use of strength-based approaches with clients and dedicated staff resources, within clear guidelines and frameworks, was reported to be necessary to maximise FFP delivery. This review proposes a complex FFP dynamic whereby practitioners engage in a constant balancing act between FFP stakeholders to achieve meaningful FFP outcomes for service-users and their families. Service recommendations are provided.

Although many people with psychosis are parents, managing the dual demands of poor mental health and parenting can be stressful and may contribute to poorer outcomes for both parent and child. Parenting interventions have the potential to improve outcomes for the whole family but need evaluation of feasibility in this context. The Triple-P Self-Help Workbook was implemented with guidance and support with 10 parents experiencing psychosis in a multiple baseline case series study. Sessions were weekly and home-based. Outcome measures examined facets of parenting, child behavior, self-efficacy and parental mental health. Follow up interviews explored parents' perspectives of the perceived impact of the intervention and apparent mechanisms of change. The program resulted in clinically significant change (>25% improvement) in mental health, parenting and child behavior measures post-intervention for the 50% who completed all 10 sessions and improvements were maintained at 3 and 6 month follow up. Interviews with those who completed the program revealed it to have been transformative: parents reported positive changes in parenting style; they were empowered with regard to their parenting and had a greater sense of control over their mental health. This study provides preliminary evidence that self-directed Triple P might be able to reduce the symptoms of psychosis by improving family functioning. Findings could inform the future development or adaptation of evidence-based parenting interventions for parents with psychosis in order to improve their mental health, aid recovery, and intervene early in the lives of children at risk of poor long-term outcomes.

We examined expressed emotion (EE) and attributions in parents with schizophrenia and compared them to parents without serious mental illness (SMI) in order to better understand the emotional climate of families in which a parent has schizophrenia. Parenting practices and parental reports of child behavior were also compared between the two groups. The relationship of EE to attributions was examined in each group separately. Relationships between parental mental health, EE, and attributions were explored in the parents with schizophrenia only. The Camberwell Family Interview was used to determine both EE and attributions in 20 parents with schizophrenia and 20 parents without SMI. We found that more parents with schizophrenia were rated as high EE than those without (60 and 35%, respectively) although this was not a statistically significant difference. Parents with schizophrenia demonstrated significantly more hostility and criticism toward their children than those without SMI and made more child-blaming attributions. Blame was associated with increased hostility, less warmth, and fewer positive remarks. Parental warmth was related to greater parenting self-efficacy, less harsh parenting practices, better child behavior, and a more positive parent–child relationship. We conclude that EE and attributions are potential explanatory variables to be considered in the development of preventative and early intervention strategies for families with a parent with schizophrenia or other psychotic disorder. Blame and warmth are modifiable factors that could be targeted within family and parenting interventions.