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NIHR Signal Psychological therapies may improve parenting skills in parents of children with chronic illness

Published on 13 June 2019

doi: 10.3310/signal-000778

Psychological therapies appear to show promise in helping improve self-reported parenting behaviour of parents of children and adolescents with cancer, chronic pain, diabetes or traumatic brain injury.

Cognitive behavioural therapy (CBT) and problem-solving therapy (PST) appear particularly valuable in supporting this. Psychological therapies also seemed beneficial in improving the mental health of parents who have children with cancer and chronic pain, but not in studies of children with diabetes.

Parenting a child with a chronic illness can pose challenges to family life, causing emotional strain for both the parents and children concerned. Skills for adapting to this can help improve parenting behaviour and the mental health and well-being outcomes for families of children with chronic illness.

This Cochrane systematic review analysed 44 trials of varying quality, which included over 4,600 parents. The results may help support healthcare practitioners working with families where children have chronic illness.

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Why was this study needed?

Chronic medical conditions such as asthma, diabetes mellitus and chronic pain in childhood and adolescence can impact poorly on quality of life and be potentially life-threatening. Parents and families play a critical role in helping their children adapt to chronic illness, and this can be stressful. All aspects of daily life for both the parents and child can be negatively affected.

Parents of children with chronic medical conditions are more likely to experience emotional distress such as anxiety and depression, unsuitably adapted parenting responses and poor family functioning. This has been linked to poorer social and educational outcomes for the child.

Worldwide, chronic medical conditions in childhood and adolescence are expected to increase over time. A better understanding is needed of what psychological treatments can help support parents and children to cope more effectively with chronic illness.

What did this study do?

This updated Cochrane review found 44 randomised controlled trials that compared psychological and non-psychological therapies given to parents of children with common chronic illnesses. The largest number of studies came from parents of children with diabetes and chronic pain. The review included 4,697 parents and other primary caregivers of children and adolescents aged three months to 19 years with chronic medical conditions lasting beyond three months.

Studies included the use of psychotherapeutic treatments focussed on improving the behaviours and mental health of parents measured by self-reporting on various outcome scales. Studies were chosen that compared psychological therapies such as CBT, PST, motivational interviewing and family therapy delivered face-to-face with any other treatment or no treatment. It was unclear whether participants had a current psychological diagnosis.

Most studies were of low quality apart from those measuring parental mental health.

What did it find?

  • Cognitive behavioural therapy (CBT) and problem-solving therapy (PST) showed the most promise for improving reported parenting behaviour for parents of children with cancer, chronic pain, diabetes and traumatic brain injury.
  • Psychological therapies appeared to sustainably improve parenting behaviour for children with cancer (mean difference at three months follow-up -0.21, 95% confidence interval [CI] -0.37 to -0.05; 625 parents) and children with chronic pain (mean difference at three to 12 months follow-up -0.35, 95% CI -0.50 to -0.20; 678 parents).
  • Psychological therapies appeared to improve parenting behaviour after the therapy ended for children with diabetes (mean difference -1.39, 95% CI -2.41 to -0.38; 338 parents) and traumatic brain injury (mean difference -0.74, 95% CI -1.25 to -0.22; 254 parents).
  • The mental health of parents of children with cancer appeared to be sustainably improved by psychological therapies (mean difference -0.23, 95% CI -0.39 to -0.08; 667 parents) and of children with chronic pain (mean difference -0.20, 95% CI -0.38 to -0.02; 482 parents).
  • Child mental health symptoms post-treatment were improved after their parents received psychological therapy (mean difference -0.08, 95% CI -0.19 to 0.03; 1,786 parents).

What does current guidance say on this issue?

National guidelines from NICE for most of the chronic illnesses considered in this study do not make detailed recommendations about psychological treatments in terms of parental support.

Most focus on the clinical management of the condition and make broad recommendations on accessing charitable organisations and other local and national support and information services. Guideline development is currently in progress or identified as needed in other areas.

What are the implications?

This review indicates that in some areas, psychological therapies have beneficial effects in improving parenting skills and mental health in parents of children with chronic illness. Family functioning and parent and child well-being may be aided by this, leading to better overall adaptation to coping with illness.

Current clinical guidelines place little emphasis on psychological therapies and in many cases refer service users to charitable organisations and national support services. These options, alongside strong social support, are likely to be helpful. Where there is less opportunity to access this type of support, CBT and PST may present viable alternative options. The costs and cost-effectiveness of these options did not form part of this review.

Citation and Funding

Law E, Fisher E, Eccleston C and Palermo TM. Psychological interventions for parents of children and adolescents with chronic illness. Cochrane Database Syst Rev. 2019;3:CD009660.

Cochrane UK and the Pain, Palliative and Supportive Care Review Group (PaPaS) Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

Cousino MK and Hazen RA. Parenting stress among caregivers of children with chronic illness: a systematic review. J Pediatr Psychol. 2013;38(8):809‐28.

Leeman J, Crandell JL, Lee A et al. Family functioning and the well‐being of children with chronic conditions: a meta‐analysis. Res Nurs Health. 2016; 39:229‐43.

Liu L, Oza S, Hogan D et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post‐2015 priorities: an updated systematic analysis. Lancet, 2015; 385:430‐40.

NICE. Cancer services for children and young people. QS55. London: National Institute for Health and Care Excellence; 2014.

NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. London: National Institute for Health and Care Excellence; 2017.

NICE. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. NG18. London: National Institute for Health and Care Excellence; 2016.

NICE. Head Injury. QS74. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

Chronic medical conditions such as asthma, diabetes mellitus and chronic pain in childhood and adolescence can impact poorly on quality of life and be potentially life-threatening. Parents and families play a critical role in helping their children adapt to chronic illness, and this can be stressful. All aspects of daily life for both the parents and child can be negatively affected.

Parents of children with chronic medical conditions are more likely to experience emotional distress such as anxiety and depression, unsuitably adapted parenting responses and poor family functioning. This has been linked to poorer social and educational outcomes for the child.

Worldwide, chronic medical conditions in childhood and adolescence are expected to increase over time. A better understanding is needed of what psychological treatments can help support parents and children to cope more effectively with chronic illness.

What did this study do?

This updated Cochrane review found 44 randomised controlled trials that compared psychological and non-psychological therapies given to parents of children with common chronic illnesses. The largest number of studies came from parents of children with diabetes and chronic pain. The review included 4,697 parents and other primary caregivers of children and adolescents aged three months to 19 years with chronic medical conditions lasting beyond three months.

Studies included the use of psychotherapeutic treatments focussed on improving the behaviours and mental health of parents measured by self-reporting on various outcome scales. Studies were chosen that compared psychological therapies such as CBT, PST, motivational interviewing and family therapy delivered face-to-face with any other treatment or no treatment. It was unclear whether participants had a current psychological diagnosis.

Most studies were of low quality apart from those measuring parental mental health.

What did it find?

  • Cognitive behavioural therapy (CBT) and problem-solving therapy (PST) showed the most promise for improving reported parenting behaviour for parents of children with cancer, chronic pain, diabetes and traumatic brain injury.
  • Psychological therapies appeared to sustainably improve parenting behaviour for children with cancer (mean difference at three months follow-up -0.21, 95% confidence interval [CI] -0.37 to -0.05; 625 parents) and children with chronic pain (mean difference at three to 12 months follow-up -0.35, 95% CI -0.50 to -0.20; 678 parents).
  • Psychological therapies appeared to improve parenting behaviour after the therapy ended for children with diabetes (mean difference -1.39, 95% CI -2.41 to -0.38; 338 parents) and traumatic brain injury (mean difference -0.74, 95% CI -1.25 to -0.22; 254 parents).
  • The mental health of parents of children with cancer appeared to be sustainably improved by psychological therapies (mean difference -0.23, 95% CI -0.39 to -0.08; 667 parents) and of children with chronic pain (mean difference -0.20, 95% CI -0.38 to -0.02; 482 parents).
  • Child mental health symptoms post-treatment were improved after their parents received psychological therapy (mean difference -0.08, 95% CI -0.19 to 0.03; 1,786 parents).

What does current guidance say on this issue?

National guidelines from NICE for most of the chronic illnesses considered in this study do not make detailed recommendations about psychological treatments in terms of parental support.

Most focus on the clinical management of the condition and make broad recommendations on accessing charitable organisations and other local and national support and information services. Guideline development is currently in progress or identified as needed in other areas.

What are the implications?

This review indicates that in some areas, psychological therapies have beneficial effects in improving parenting skills and mental health in parents of children with chronic illness. Family functioning and parent and child well-being may be aided by this, leading to better overall adaptation to coping with illness.

Current clinical guidelines place little emphasis on psychological therapies and in many cases refer service users to charitable organisations and national support services. These options, alongside strong social support, are likely to be helpful. Where there is less opportunity to access this type of support, CBT and PST may present viable alternative options. The costs and cost-effectiveness of these options did not form part of this review.

Citation and Funding

Law E, Fisher E, Eccleston C and Palermo TM. Psychological interventions for parents of children and adolescents with chronic illness. Cochrane Database Syst Rev. 2019;3:CD009660.

Cochrane UK and the Pain, Palliative and Supportive Care Review Group (PaPaS) Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

Cousino MK and Hazen RA. Parenting stress among caregivers of children with chronic illness: a systematic review. J Pediatr Psychol. 2013;38(8):809‐28.

Leeman J, Crandell JL, Lee A et al. Family functioning and the well‐being of children with chronic conditions: a meta‐analysis. Res Nurs Health. 2016; 39:229‐43.

Liu L, Oza S, Hogan D et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post‐2015 priorities: an updated systematic analysis. Lancet, 2015; 385:430‐40.

NICE. Cancer services for children and young people. QS55. London: National Institute for Health and Care Excellence; 2014.

NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. London: National Institute for Health and Care Excellence; 2017.

NICE. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. NG18. London: National Institute for Health and Care Excellence; 2016.

NICE. Head Injury. QS74. London: National Institute for Health and Care Excellence; 2014.

Psychological interventions for parents of children and adolescents with chronic illness

Published on 19 March 2019

Law, E.,Fisher, E.,Eccleston, C.,Palermo, T. M.

Cochrane Database Syst Rev Volume 3 , 2019

BACKGROUND: Psychological therapies for parents of children and adolescents with chronic illness aim to improve parenting behavior and mental health, child functioning (behavior/disability, mental health, and medical symptoms), and family functioning.This is an updated version of the original Cochrane Review (2012) which was first updated in 2015. OBJECTIVES: To evaluate the efficacy and adverse events of psychological therapies for parents of children and adolescents with a chronic illness. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, and trials registries for studies published up to July 2018. SELECTION CRITERIA: Included studies were randomized controlled trials (RCTs) of psychological interventions for parents of children and adolescents with a chronic illness. In this update we included studies with more than 20 participants per arm. In this update, we included interventions that combined psychological and pharmacological treatments. We included comparison groups that received either non-psychological treatment (e.g. psychoeducation), treatment as usual (e.g. standard medical care without added psychological therapy), or wait-list. DATA COLLECTION AND ANALYSIS: We extracted study characteristics and outcomes post-treatment and at first available follow-up. Primary outcomes were parenting behavior and parent mental health. Secondary outcomes were child behavior/disability, child mental health, child medical symptoms, and family functioning. We pooled data using the standardized mean difference (SMD) and a random-effects model, and evaluated outcomes by medical condition and by therapy type. We assessed risk of bias per Cochrane guidance and quality of evidence using GRADE. MAIN RESULTS: We added 21 new studies. We removed 23 studies from the previous update that no longer met our inclusion criteria. There are now 44 RCTs, including 4697 participants post-treatment. Studies included children with asthma (4), cancer (7), chronic pain (13), diabetes (15), inflammatory bowel disease (2), skin diseases (1), and traumatic brain injury (3). Therapy types included cognitive-behavioural therapy (CBT; 21), family therapy (4), motivational interviewing (3), multisystemic therapy (4), and problem-solving therapy (PST; 12). We rated risk of bias as low or unclear for most domains, except selective reporting bias, which we rated high for 19 studies due to incomplete outcome reporting. Evidence quality ranged from very low to moderate. We downgraded evidence due to high heterogeneity, imprecision, and publication bias.Evaluation of parent outcomes by medical conditionPsychological therapies may improve parenting behavior (e.g. maladaptive or solicitous behaviors; lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.28, 95% confidence interval (CI) -0.43 to -0.13; participants = 664; studies = 3; SMD -0.21, 95% CI -0.37 to -0.05; participants = 625; studies = 3; I(2) = 0%, respectively, low-quality evidence), chronic pain post-treatment and follow-up (SMD -0.29, 95% CI -0.47 to -0.10; participants = 755; studies = 6; SMD -0.35, 95% CI -0.50 to -0.20; participants = 678; studies = 5, respectively, moderate-quality evidence), diabetes post-treatment (SMD -1.39, 95% CI -2.41 to -0.38; participants = 338; studies = 5, very low-quality evidence), and traumatic brain injury post-treatment (SMD -0.74, 95% CI -1.25 to -0.22; participants = 254; studies = 3, very low-quality evidence). For the remaining analyses data were insufficient to evaluate the effect of treatment.Psychological therapies may improve parent mental health (e.g. depression, anxiety, lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.21, 95% CI -0.35 to -0.08; participants = 836, studies = 6, high-quality evidence; SMD -0.23, 95% CI -0.39 to -0.08; participants = 667; studies = 4, moderate-quality evidence, respectively), and chronic pain post-treatment and follow-up (SMD -0.24, 95% CI -0.42 to -0.06; participants = 490; studies = 3; SMD -0.20, 95% CI -0.38 to -0.02; participants = 482; studies = 3, respectively, low-quality evidence). Parent mental health did not improve in studies of children with diabetes post-treatment (SMD -0.24, 95% CI -0.90 to 0.42; participants = 211; studies = 3, very low-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent mental health.Evaluation of parent outcomes by psychological therapy typeCBT may improve parenting behavior post-treatment (SMD -0.45, 95% CI -0.68 to -0.21; participants = 1040; studies = 9, low-quality evidence), and follow-up (SMD -0.26, 95% CI -0.42 to -0.11; participants = 743; studies = 6, moderate-quality evidence). We did not find evidence for a beneficial effect for CBT on parent mental health at post-treatment or follow-up (SMD -0.19, 95% CI -0.41 to 0.03; participants = 811; studies = 8; SMD -0.07, 95% CI -0.34 to 0.20; participants = 592; studies = 5; respectively, very low-quality evidence). PST may improve parenting behavior post-treatment and follow-up (SMD -0.39, 95% CI -0.64 to -0.13; participants = 947; studies = 7, low-quality evidence; SMD -0.54, 95% CI -0.94 to -0.14; participants = 852; studies = 6, very low-quality evidence, respectively), and parent mental health post-treatment and follow-up (SMD -0.30, 95% CI -0.45 to -0.15; participants = 891; studies = 6; SMD -0.21, 95% CI -0.35 to -0.07; participants = 800; studies = 5, respectively, moderate-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent outcomes.Adverse eventsWe could not evaluate treatment safety because most studies (32) did not report on whether adverse events occurred during the study period. In six studies, the authors reported that no adverse events occurred. The remaining six studies reported adverse events and none were attributed to psychological therapy. We rated the quality of evidence for adverse events as moderate. AUTHORS' CONCLUSIONS: Psychological therapy may improve parenting behavior among parents of children with cancer, chronic pain, diabetes, and traumatic brain injury. We also found beneficial effects of psychological therapy may also improve parent mental health among parents of children with cancer and chronic pain. CBT and PST may improve parenting behavior. PST may also improve parent mental health. However, the quality of evidence is generally low and there are insufficient data to evaluate most outcomes. Our findings could change as new studies are conducted.

Expert commentary

This is a highly competent review, but it is difficult to draw clinical conclusions. Most parents of chronically ill children are able to manage the stress involved using their own personal and social resources. They are therefore unlikely to require specialised interventions such as reviewed here. In addition, the stress varies according to type of disorder, illness stage and severity.

The review would have been more informative for clinicians had it addressed more clinically homogeneous populations and focused on interventions for parents who do develop unhelpful, persistent styles of parenting, or for those with significant mental health problems. 

Elena Garralda, Emeritus Professor of Child and Adolescent Psychiatry, Imperial College London

The commentator declares no conflicting interests