THE EFFICACY OF FAMILY COGNITIVE BEHAVIOURAL THERAPY AT A YOUTH PSYCHIATRIC CLINIC IN KENYA
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ABSTRACT

The association between psychiatric illness in parents and their ability to parent, as well as the effect of the parenting behaviour on their children has both clinical and public mental health policy relevance. Cognitive Behaviour Therapy (CBT) is an evidence-based clinical practice that reduces relapse rates and facilitates the recovery of persons who have mental illness when combined with standard psychiatric treatment methods. A core set of characteristics of effective CBT programs have been developed worldwide, including specific psycho-therapeutic approaches, provision of emotional support, psycho-education, and problem solving skills and other resources like bringing the family together during periods of psychotherapy.

This clinical trial study was conducted to determine whether: (1) Maladaptive parenting behaviour is associated with parental and youths psychiatric disorders; (2) Combined Family Cognitive Behaviour Therapy (F-CBT) with Standard Methods of Psychiatric Treatment Methods (SPTM) have better outcome in treating Diagnostic and Statistical Manual 4th Edition (DSM-IV) axis 1 psychiatric disorders found among family members than the SPTM alone.

History, psychological examinations and structured psychiatric interviews were carried out from a total sample of 678 participants; 250 youths, 226 mothers and 202 fathers to determine current psychiatric disorders at: baselines 1, 2 and 3. Maladaptive parenting behaviours and mental state functioning were assessed using the Egna Minnen Betraffande Uppfostran (Swedish acronym of My Memories of upbringing-EMBU) and Mini Mental State Examination (MMSE) questionnaires respectively. Psychiatric disorders were assessed using Mini International Neuropsychiatric Interview for Youths and Adolescents (MINI –Kid) administered to youth and Mini International Neuropsychiatric Interview for Adults (MINI-PLUS) administered to parents. The study instituted combined F-CBT with SPTM participants allocated in the experimental group and SPTM alone to those in the control group.

Most of youth in the study perceived their parents to have high levels of maladaptive parenting behaviour, whether or not the parents had a psychiatric disorder: 55.1%, 23.9% and 12.4% of mothers were perceived to have rejecting, under protective and no emotional attachment parenting behaviours respectively compared to 8.5% who were perceived to have adaptive (normal) parenting behaviour. Among fathers: 24.9%, 53.8% and 7.6% were perceived to have rejecting, under protective and no emotional attachment parenting behaviour respectively compared to 13.7% fathers who were perceived to have adaptive parenting behaviour. Most of the mothers who had depressive disorders (51.3%), were perceived to interact with their youths using a rejecting parenting behaviour than mothers with any other/ or without a psychiatric disorder.  The presence of maternal depressive disorder was associated with increased odds ratio of 2.14 for Major Depressive disorder (MDD) and also suicidal behaviour among the youth compared to mothers who had no depression. Fathers with alcohol use disorders had higher levels of maladaptive paternal parenting behaviour than did fathers without alcohol use disorders. Youths who had seen their father drunk/using alcohol excessively had high odds ratio of 2.82 of having alcohol dependence than youths who had not seen their father drunk/use alcohol excessively. The proportions of youths with alcohol use disorder (44.4%) and had peers using alcohol was higher than the proportion of youths with alcohol use disorders (8.3%) but did not have peers using alcohol. Alcohol use disorder among fathers was also associated with increased maternal odds ratio  (2.42) of having depressive disorder.

The families allocated to the experimental group had better outcome in terms of response to treatments as compared to the control group. For MDD in the youth, in the control group, there was hardly any reduction in prevalence of MDD between baseline 1 and 2 and minimal to moderate reduction (18%) between baseline 2 and 3. However in the experimental group there was drastic reduction in prevalence of MDD from baseline 1 to 2 (by 35.3%) and also from baseline 2 to 3 from 7.8% to 2.6% respectively. With regard to suicide behaviour, there was no suicidal behaviour detected in the experimental group at baselines 2 and 3. In the control, there was a 50% reduction between baseline 1 and 2 and hardly any reduction between baseline 2 and 3. For alcohol use disorders, there was significant reduction in prevalence among experimental group between baseline 1 and 2 (p=0.001) and also between baseline 2 and 3 resulting in no alcohol use disorder at baseline 3, p<0.001. In the control, there was a hardly any reduction between baseline 1 and 2 (p=0.796) and significant reduction between baseline 2 and 3 (p=0.002). In the intervention for drug abuse, there was more than half reduction in prevalence in the experimental group between baseline 1 and 2 (p<0.001) and also between baseline 2 and 3 resulting in no drug abuse disorder at baseline 3, p<0.001. In the control, there was a hardly any reduction between baseline 1 and 2 (p=0.695) but there was a significant reduction between baseline 2 and 3 (p=0.001). In relation to depression in mothers, the experimental group had a significant reduction in the prevalence between baseline 1 and 2, p=0.012 and also between baseline 2 and 3, p<0.001.  In the control, there was a hardly any reduction between baseline 1 and 2 (p=0.896) and but a significant reduction between baseline 2 and 3 (p=0.004). Regarding to alcohol use among fathers, at baselines 2 after 3months, the control group had significantly more fathers with alcohol use disorders than the experimental group (p<0.001). The fathers in experimental group had significant reduction in alcohol use, p<0.001. 

These results provide vital insights into intergenerational effects of parenting behaviour and parents’ psychopathology on child and youth development. The study adds to the body of research on role of parenting behaviour and parental psychiatric disorders by focusing on youth’s psychiatric and substance use disorders including alcohol use and dependence as outcomes in the study. Collectively, these findings indicate that perceived maladaptive parenting behaviour, depressive and alcohol disorders among parents are risk factors in a family setting that make youth vulnerable to develop common mental disorders. Although perceived parenting behaviour models play different roles for different youth psychosocial outcomes, overall, the results support attachment theory. Having a mother with depression and maladaptive rejecting parenting behaviour is a precursor for a child, and subsequently the youth, to develop psychiatric disorders. These findings are consistent with the hypothesis that mothers may be vital resources to help protect youth from the noxious effects of the risks they face. The findings also suggest that efforts to develop and improve child-parent relationships may be beneficial. There is also a strong evidence for associations between SUDs and other psychiatric disorders; MDD, conduct disorder, suicide behaviour and alcohol use among youth and other factors such as rejecting perceived maternal parenting behaviour and having peers who use alcohol. These results provide further specification of the association between SUDs and other psychiatric disorders, perceived parenting behaviour and having peers who use alcohol. The maladaptive parenting behaviour and psychiatric disorders therefore substantially mediates clinically significant associations between parental and youth psychiatric disorders.

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