Family Support in Children’s Mental Health: A Review and Synthesis
Kimberly E. Hoagwood • Mary A. Cavaleri • S. Serene Olin • Barbara J. Burns • Elaine Slaton • Darcy Gruttadaro • Ruth Hughes

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Abstract: A comprehensive review of structured family support programs in children’s mental health was conducted in collaboration with leadership from key national family organizations. The goals were to identify typologies of family support services for which evaluation data existed and identify research gaps. Over 200 programs were examined; 50 met criteria for inclusion. Programs were categorized by whether they were delivered by peer family members, clinicians, or teams. Five salient components of family support were identified: (a) informational, (b) instructional, (c) emotional, (d) instrumental, and (e) advocacy. Clinician-led programs were heavily represented (n = 33, 66%), followed by family-led (n = 11, 22%), and team-delivered (n = 6, 12%) programs. Key differences between programs delivered by clinicians or by peer family members were found in the degree of emphasis, research methodology, and outcomes. However, the content of the components was similar across all three program types. There are both important differences in emphasis across typologies of family support provided by clinicians, family members, or teams as well as important similarities in content. Family-delivered support may be an important adjunct to existing services for parents, although the research base remains thin. A research agenda to promote more rigorous evaluations of these services especially those delivered by peer family members is critical.

Discussion
This review highlights strengths and weaknesses in studies of family support services for parents of youth with mental health problems. The purpose of the review is to provide conceptual consistency in the definition of this service, to identify typologies and core components of these services, and to assess the status of research on its impact. Three salient models characterized the 50 studies we evaluated; programs led by a clinician, the more traditional model; those led by a family member, a newer model; and those led by a team, the least developed but most recent model. We identified five core components and functions that captured (broadly) the range of services: information sharing (or education), skill development, emotional support, instrumental support (i.e., concrete services), and advocacy support. What is unique about family support services, as opposed to traditional clinical care, is that they are designed to assist parents in clarifying their own needs or concerns, reducing their sense of isolation, stress, or self-blame, and empowering them to take an active role in their children’s services. We found that the specific functions and activities that constituted each of the five components of family support were quite similar irrespective of who provided the service or where it was provided. Differences were found in emphasis (mixture of components) and even more starkly, in the extent to which the program models had a research base. We found substantial unevenness in the distribution of models (i.e., family led, clinician led, team led) and in the quality of evaluation data. Two-thirds of programs were led by clinicians; less than a quarter of programs were led by family members and only a handful represented a team based collaboration between a mental health clinician and a family member. Despite the surge of interest in family-driven service models, few such models have been systematized and developed to the point that evaluations have been conducted. Instead, the bulk of the extant programs are clinician led.

Key Findings: Program and Participant Characteristics
Almost unanimously, family and team-led programs were not delivered in clinical settings, but rather in community settings. In addition, the majority of the family-led programs were affiliated with national or local family-run organizations. Team-led programs were typically affiliated with universities and developed and delivered by researchers who collaborated with family members through federally funded research efforts. Almost all the clinician-led programs were based in clinical settings, with family support services almost always contingent on the child having a diagnosis, being an identified patient, or in concurrent treatment. In contrast, family and team-led programs were less likely to place constraints on eligibility for family support services, other than having a child with an identified mental health need.

Key Findings: Types of Parent Support
Overall, similar types of functions or activities (i.e., education/ information, emotional, skill building) were represented across the three different provider categories. However, the content and emphasis differed across providers. Thus, clinician-led programs were more likely to focus on skill building related to managing the child’s mental health issues, while family-led programs emphasized parent cognitions about their experiences, with the goal of problem-solving child management issues. Clinician-led programs tended to be grounded in behavioral or cognitive behavioral theories, focusing primarily on parenting skill building to manage child symptoms. As noted in a recent review of parent engagement in the behavioral parent training literature, a key limitation of such programs is the exclusion of parent’s emotional experiences and social cognitions related to the acceptability of these methods (Mah and Johnston 2008). Within family-led programs, skill building focused more on parents’ own needs involving personal coping, stress, and anger management, communication and problem-solving skills, respite and self-care. Clinician-led programs tended to focus on the parents’ own needs but in the service of increasing the parents’ capacity to support the child’s compliance with treatment (e.g., help parent manage own anxiety so parent can support child adherence to exposure exercises). Family-led programs were also more likely to emphasize advocacy supports, and more apt to recognize and discuss system level barriers rather than parent-level barriers to service access. Advocacy and instrumental support were not a core component of the programs provided by clinicians, whereas they were more often included in family-led programs. In addition, family-led programs were more likely to emphasize emotional support through shared experiences, often with a goal of reducing parental isolation and stigma. Team-led programs appeared to be more comprehensive, with a more balanced emphasis across the various types of support: instructional, informational, advocacy, and emotional. Team-led programs were also more likely to provide instrumental supports than family-led or clinician- led programs.

Key Findings: Strength of the Data
Programs led by clinician or clinician-family teams have been far more rigorously studied than family-led models. Clinician-led programs are more likely to have used experimental designs, most often with random assignment. Family-led programs have received much less federal research support and therefore have relied on weaker evaluation designs and consequently have a much thinner evidence base. Where evaluation data exist, pre–post designs with weak or no comparison groups were the predominant design. In terms of outcomes, family-led programs were more likely to focus on caregiver satisfaction or caregiver perceived support. This is in keeping with the primary focus of family-led programs on targeting caregiver isolation and providing information and education. Outcomes in clinician- led models tended to focus on reduction in child’s symptoms, improvement in functioning, and parent mental health or stress reduction. Among clinician-led programs, the findings from the research clearly demonstrated the value of family support services. In general, support services for parents produced superior child outcomes to standard treatment alone. This held whether the program was an independent intervention, an augmentation to standardized child treatment, or an integrated component of child treatment. In addition to augmenting child outcomes, these studies found that parent support conferred important benefits for the parents, improving mental health and well-being, increasing self-efficacy, reducing stress, and improving perceived social supports and skills. It also improved family functioning, increased treatment engagement, and reduced barriers to care. Families support services are likely to grow in the coming years in part because this type of service is adaptable to the needs of different families, can be individualized, is likely to be cost-effective (although that has not been established), and is a natural gate-way into mental health services for parents who might otherwise shun them. For example, family support is likely to be especially helpful for parents who have experienced blame stemming from the stigma of mental health, parents with different cultural frameworks, or parents who have had negative experiences with the system. In an important new development, this service model is becoming increasingly professionalized as states undertake the process of making it a billable service (NY) and create credentialing programs to certify peer parent providers to deliver this service. Given the growing workforce shortage, the availability of a cadre of highly trained professional family advisors delivering effective family support services may assist the mental health system as it is transformed under new paradigms of health care.

Future Research
Despite its promise, and relative to other scientific subfields in children’s mental health, family support has received limited research attention. This is due in part to sloppiness in defining either the parameters of ‘‘support,’’ its core functions, the competencies needed to deliver it well, or the outcomes it is intended to effect. The field is awash in different terms, interpretations, and other verbal debris that obfuscate the potential of this service. Such ambiguity has prevented the development of a clear framework for understanding and systematically studying family support and its impact. This review provides an important first step in operationalizing and characterizing key components of family support. A clear conceptual framework is needed to guide future studies. This review provides some insight into components of family support and suggests what the contours of a framework might include. In our view, a comprehensive conceptualization could be drawn from theory and research on behavior change (Jaccard et al. 2002), patient activation (Alegria et al. 2008), self-efficacy (Bandura 1977, 1986), and empowerment (Sarason et al. 1990; Santelli et al. 1993). A comprehensive model will need to include attention to mediators of parent and child outcomes (e.g., does emotional support that reduces shame, self-blame, and isolation increase parent activation and self-efficacy that in turn positively impact child and family functioning?) The components of family support fit well within the Unified Theory of Behavior’s (UTB) explanatory model (Jaccard et al. 2002). For instance, information and education may shape parents’ expectancies, attitudes, and beliefs; emotional support is likely to influence perceptions of social norms; instrumental support and advocacy may address environmental constrains; skill building is likely to influence self-efficacy). Considerable work is needed to outline thoroughly the logic model underpinning family support, as well as the most salient outcome measures for assessing change, but this we believe is a necessary next step. A range of studies is needed to fill this vacuum. These include mediator and moderator analyses of the impact of family support to identify what factors account for outcomes. It will not be sufficient to document evidence of effective family support interventions if concurrent attention is not paid to the mechanisms by which impact is attained. There is a need for intervention enhancement studies (e.g., adding family support to other interventions) to assess its comparative effectiveness. To develop a science on individualized care, it will be necessary to launch studies that identify which components are most helpful to which types of parents or at what particular junctures in their personal journey. The development of the evidence base in children’s mental health has been largely driven by researchers who have historically focused on improving child outcomes, assessed in terms of psychiatric symptoms (e.g., CBCL scales, diagnoses or items from the DISC) or generalized functioning (e.g., CGAS). Even among those treatment studies that provide caregiver support, caregiver outcomes are often focused on parent pathology (e.g., depression/ anxiety/psychiatric symptomatology), and more relevant caregiver measures (e.g., caregiver strain, parental stress) are often not measured. Asynchrony exists. Likewise, the limited evaluations that currently characterize most family-led services have failed to yield scientifically generalizable knowledge. To advance the science in this area and keep pace with its rapid emergence as a promising adjunctive service, new paradigms of scientific collaborations involving researchers and family advocates are essential.

Hoagwood, K., Cavaleri, M., Serene Olin, S., Burns, B., Slaton, E., Gruttadaro, D., & Hughes, R. (2010). Family support in Children’s mental health: A review and synthesis. Clinical Child & Family Psychology Review, 13(1), 1-45. doi:10.1007/s10567-009-0060-5

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