Strengthening Family Ties:

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Strengthening Family Ties

• The DOs and DONTs of
• Parent-Teen Conflict
• Mary Beth Rucki, RN, MSN, APRN
• Services for Teens at Risk
• (STAR-Center)

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Objectives

• Participants will have an increased understanding
  of the role of family conflict on adolescents.
• Participants will have an increased understanding
  of the role of mood disorder on adolescent
  behavior.
• Participants will be able to identify 3 skills
  that can help reduce parent-teen conflict.

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Family Factors and Teen Depression - 1

• Empirical evidence links a multitude of family
  environmental factors to the development,
  maintenance, and likelihood of relapse of major
  depressive illness in children and adolescents.
  (Kaslow, et. al., 1994, Sheeber, et. al., 1997,
  2001, Birmaher, et. al., 2000)

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Family Factors and Teen Depression - 2

• Garrison, et. al. (1997) found that low family
  cohesion was a significant predictor of Major
  Depression in adolescents.
• Birmaher, et. al. (2000) found that lower levels
  of self-reported parent-child conflict predicted
  recovery from depression and increased
  self-reported parent-child conflict predicted
  persistent depression.

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Family Factors and Teen Depression - 3

• Summerville, et. al. (1994) studied 121
  adolescent suicide attempters
• 67 classified their family types as maladaptive
  in terms of cohesion and/or adaptability.
• The majority of teens and parents in the study
  reported their families as disengaged.

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Family Factors and Teen Depression - 4

• Sheeber, et. al. (1997) examined the relationship
  between family support, family conflict, and
  adolescent depression in 420 male and female
  teens.
• Higher family conflict was associated with more
  depressive symptoms.
• Adolescent symptoms did not predict deterioration
  in family relationships.

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Evidence-based Treatment ??
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Results Mixed - 1

• Lewinsohn, et. al. (1990) added parent training
  group to CBT skills group for depressed
  adolescents. No additional benefit was found.
• Brent, et. al. (1997) found CBT more effective
  than family or individual supportive therapy on
  some indicators, but no group differences on
  suicidality or functional status.

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Results Mixed - 2

• Diamond, et. al. (2002) found that
  Attachment-Based Family Therapy (ABFT) was
  significantly effective when compared with
  control group. These patients showed
• Higher levels of attachment to mothers
• Lower levels of suicidal ideation and
  hopelessness
• Significantly less family conflict
• 81 no longer met criteria for MDD

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Potential Family Factors to Address - 1

• Poor Attachment
• High levels of Criticism
• Ineffective Parenting
• Parental Pathology (Diamond, et. al. 2002)

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Potential Family Factors to Address - 2

• Stress/Support
• Social Interaction
• Cognitive
• Affect Regulation (Sheeber, et. al., 2001)

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Improving Attachment

• Traditional Family Therapy
• Attachment Based Family Therapy
• Resolving core family conflicts
• Strengthening attachment to parents
• Rebuilding trust in and communication with parents

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Reducing High Levels of Criticism

• Psychoeducation
• Clarifying diagnosis and symptoms
• Communication skills
• Rebuilding trust
• Resolving conflict

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Reducing Criticism Parent Psychoeducation - 1

• Psychoeducation with parents should focus on
  information about depression and how it affects
  their child.
• This can be done via Parents Group, with teen
  and parent together, or alone with parents if
  appropriate.

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Reducing Criticism Parent Psychoeducation - 2

• Depression is an illness
• Review causes, symptoms, treatments
• Contributing factors vs. causes
• Depression runs in families
• Remove blamecommon enemy metaphor
• Allow them to discuss how this has affected them,
  the family
• What do they think led to this?

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Reducing Criticism Parent Psychoeducation - 3

• Depressed teens have often developed ineffective
  patterns of thought, behavior, and emotion
  (Cognitive Triad). This makes them vulnerable
  to
• Distorted thoughts about self/others
• Difficulty managing impulses
• Low tolerance for negative affect
• High reactivity

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Reducing Criticism Parent Psychoeducation - 4

• Give A-B-C example
• Activating event
• Belief
• Consequence
• Learned patterns can be unlearned, with parents
  help and support.
• It is an interactive process, without blame.

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Reducing Criticism Communication Skills

• Is this a problem? Do we want to work on it?
  (Collaboration!) If so
• Listening exercises
• Making Repair
• Assertiveness skills

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Communication Skills Listening

• Each person has something important to say.
• Both parties can be right.
• Acknowledgment doesnt mean agreement.
• Reinforces respect.
• Can help identify distortions.

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Communication Skills Making Repair

• Not necessarily accepting blame, but
  understanding and acknowledging that someone
  feels hurt or wounded
• Teach parent how to initiate this while
  acknowledging that they also feel hurt by teens
  behavior

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Communication Skills Assertiveness

• I Statements
• Identification of ones own feelings
• Acknowledgement of other position

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Enhancing Parenting

• Basic assumptions
• Setting limits
• Validation

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Enhancing Parenting Basic Assumptions

• Parents love their kids and want whats best for
  them.
• Parents are doing the best they can.
• Parents can do better.
• Parents are influenced by the way they were
  parented.

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Enhancing Parenting Setting Limits

• Acknowledge that setting limits with a depressed
  and suicidal teen is frightening
• May need to temporarily alter expectations
• Maintain structure
• Take all threats seriously and respond
  appropriately
• Balance limits with support

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Enhancing Parenting Validation

• An invalidating environment
• Rejects or trivializes communication of teens
  internal experience
• Punishes expression of negative emotions
• Intermittently reinforces emotional escalation
• Minimizes the ease of problem-solving
• (Linehan, 1993, Miller, 2002)

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Creating a More Validating Environment

• If the family environment seems to be
  invalidating, this can be addressed through
• Validation of the parent/rapport building
• Respectful inquiry
• Share your conceptualization
• Psychoeducation

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Validation of Parent

• Accurate reflection
• Acknowledge that this is a tough job, made more
  difficult because of teens current impairment.
• Validation in terms of past learning. Explore
  (respectfully) how they were parented. Does this
  influence your style? Do you want to change it?
• Do they need additional support?

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Respectful Inquiry

• How are negative emotions expressed in the
  family?
• How are limits set?
• What positive interactions occur?
• What positive reinforcements are in place?
• How do family members show affection and support?

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Share Your Conceptualization

• Setting the stage for change through
  collaborative identification of problems and
  goals
• Offering an opportunity for change through skill
  development

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Enhancing Validation Through Psychoeducation

• Parents learn skills in conjunction with teens
• Communication exercises
• Emotion regulation
• Supportive self-talk
• Model validation in joint sessions
• Create opportunities for positive interactions in
  or out of sessions

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Parental Pathology

• Several studies have shown that maternal
  depression is associated with depression in
  offspring though paternal depression is not.
  (Marmorstein Lacono, 2004)

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The Impact of Maternal Depression - 1

• Depressed women generally have more conflictual
  interactions with their children than
  non-depressed women, even when not currently
  depressed. (Hammen Brennan, 2002)
• When exposed to high levels of conflict, children
  of depressed mothers were much more likely to
  have depressive disorders than children of
  non-depressed women. (Hammen, et. al., 2004)

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The Impact of Maternal Depression - 2

• Offspring of depressed mothers have been shown to
  experience high rates of dependent, negative
  interpersonal life events. (Adrian Hammen, 1993)

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Interventions for Parental Pathology

• Always assess for family history of depression
• Assess primary caregiver for current symptoms
• Refer for treatment as necessary

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Affect Regulation Establishment of a Truce

• Helpful with highly reactive teens/parents
• Helpful when there is suicidal risk or
  self-injurious behavior
• Used often at the beginning of therapy

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Summary of Recommendations Dos

• Provide psychoeducation to parents.
• Identify problems/goals related to parent-teen
  relationship.
• Be collaborative in teaching new skills.
• Assess parents for symptoms of depression and
  refer for treatment.
• Refer for family therapy if indicated.
• Understand that parents are doing the best they
  can and they can do better!

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Summary of Recommendations Donts

• Dont assume one size fits all. We are still
  learning what works best.
• Dont leave the teen out of the loop of parent
  training.
• Dont forget to elicit feedback.

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• We acknowledge with gratitude the Pennsylvania
  Legislature for its support of the STAR-Center
  and our outreach efforts.
• This presentation may not be reproduced without
  written permission from STAR-Center Outreach,
  Western Psychiatric Institute and Clinic, 3811
  OHara Street, Pittsburgh, PA 15213 (412)
  687-2495

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• MaryBeth Rucki, RN, MSN, APRN
• STAR-Center of WPIC
• Acct 0931
• 38 slides including trailer
• slides will be picked up in the Medical Media
  offices at McKee Place
• For questions call Ranisa Rubin,
• [phone] rubinre_at_upmc.edu