Web-based Integrated Bipolar Parenting Intervention (IBPI) for Bipolar Parents of Young Children

Parenting can be a challenge for every parent, and for parents with BD, the ups and downs of mood and stress can add to the scale of this challenge(3). Individuals with BD characteristically experience periods of high mood (mania) and low mood (depression) that are noticeably different from their usual mood. Communication, impulse control and motivation are all affected by BD, making the delivery of consistent parenting more difficult(3,8). Children of parents with BD (CPB) are at significantly increased risk of a wide range of behavioural and emotional conditions including Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depression, substance use, and sleep disorders, in addition to higher rates of BD compared to the general population(4,5,9). Left untreated, behavioural and emotional problems in children of parents with BD can increase their risk of future mental health problems(2,3, 10). There is a high demand for community based parenting support, yet there are few evidence-based parenting interventions(11,12).There is also high demand for psychological support for BD(13), as evidenced by the significant BD-attributed annual costs to community mental health teams in the UK(14). However, traditional parenting interventions do not address the particular needs of people with BD, and psychological interventions do not necessarily focus on parenting skills. We aim to tackle both issues simultaneously with an integrated bipolar parenting intervention. We plan to conduct a review of the effectiveness of interventions for parents with mental health problems in the literature. We will develop a package of support materials for BD drawing on our expertise of developing and evaluating interventions for BD. These materials will be reviewed in collaboration with our Service User (SU) Focus Group (FG). We will integrate this information with the evidence-based Triple P-Positive Parenting Program(15), which is a parenting intervention that aims to build positive relationships within families and manage behaviour problems in children. Triple P Online is newly available, will be accessible to large numbers of people in time, and is less expensive than face-to-face therapy. We aim to determine the usefulness of adapting Triple P Online to parenting with BD, which has the potential to reduce risk of future emotional problems for CPB. The current study builds on pilot work conducted by our team(6) which found significant improvements in both child behaviour and parenting for families with BD for those who received a Triple P Online compared to controls. The pilot had some significant imitations, including 1) There was significant drop-out (22/54 participants) possibly partly because there was no additional provision of support for use of the web materials, which has been shown to enhance engagement(7); 2) We were not able to formally evaluate longer-term effects of the intervention or impact on parental mental health; 3).The lower age limit (2 years) was too young for effective use with the key outcome measure, the Strength and Difficulties Questionnaire (SDQ:16). We intend to address the above limitations and explore an Integrated Bipolar Parenting Intervention (IBPI). We will ask 50 parents with BD (who have at least one child aged 3-10 years and at least 10 hours of face-to-face contact with their child per week on average) to use IBPI for four months. We will obtain information on how many use the website, how they used it, and their experiences of using it. Parents will complete questionnaires about parenting problems, parenting stress, and child behaviour problems before and after using IBPI, and after 6, 9 and 12 months. Their responses will be compared to those who did not have access to the website (TAU: n=50). We will ask a sample of participants (n=10) about their experience using the intervention and a sample of children of parent participants (n=15) about family life before and after the intervention.

BD is a long term mental health problem characterised by instability in a range of important areas including mood, sleep and behaviour(3,5,17). Children of parents with BD (CPB) experience up to a 2.5-fold increased risk of developing any psychiatric disorder compared to controls (19), in addition to up to a 14-fold increased risk of developing BD (rates between 4% and 15% compared to 1%-2% in the general population)(4,5,9,19).Research indicates that family and parental communication problems are increased in CPB and that such problems are prospectively related to transition to BD(2,3, 10). All children in our pilot study (6) had emotional and behavioural problems above the clinical threshold on the Strengths and Difficulties Questionnaire (SDQ:16). Jones et al (2006) found similar high rates of psychological problems in adolescent CPB, yet none of the children were in receipt of psychological input.
Triple P (a positive parenting intervention to improve parenting skills) has demonstrated effectiveness in reducing emotional and behavioural problems in children(11). There is also increasing evidence for psychoeducational approaches and practical support for BD(21,22). Interventions that provide both treatment and prevention in a variety of modalities, including web-based interventions, are needed to reduce the burden of mental health problems(13). To address this clinical need, we intend to combine Triple P Online with evidenced-based BD support materials into an integrated intervention (IBPI) in a phase II feasibility trial. It is anticipated improved parenting skills and improved management of BD symptoms will lead to better outcomes for the children of participants with BD(9). We will use a mixed methods approach using qualitative data to finalise the intervention, and a pilot RCT evaluate feasibility acceptability of the intervention to determine indicative effect sizes for clinical outcome measures of child behaviour parenting and parent symptoms.

The need for mental health services has increased in recent years, and the number of mental health professionals is insufficient to meet this demand using traditional models of delivery (i.e. psychotherapy)(13). With the pending reforms to the National Health Service (NHS), it is anticipated that Primary Care Trusts (that currently oversee Mental Health Trusts) will be abolished by 2013. This will result in 80% of NHS funding being redirected to GP consortia(24,25). These changes will undoubtedly place additional burden on GPs and potentially reduce access to even greater numbers of people with mental health problems. This web-based parenting programme could be offered broadly, and would provide an alternative support option that GPs can recommend directly to service users at minimal cost (or through charitable organisations that offer Triple P Online for free) to reduce the heavy demand on rapidly decreasing NHS resources for mental health. The intervention could also be used as an additional resource for voluntary sector organisations (for example, MDF-The bipolar Organisation, ReThink, and MIND) seeking to support people with mental health problems.

Our team (Calam) has engaged in both quantitative and qualitative pilot work which show consistency in the views of parents with severe mental illness regarding self-management interventions, their desire to parent well, their awareness of the impact of their illness on their parenting with associated guilt and worry, and their need for support(26,27). It is proposed that the study will provide an immediate benefit to service users (and their children) who participate in the study that is comprised of evidence-based material specific for BD, and access to Triple P, which has demonstrated effectiveness at a population level targeting behavioural and emotional problems in children and their parents(28). If successful, the current study will also provide open access to the intervention to service users who participate in the TAU arm.

A report of our findings will be disseminated throughout the NHS within the 24 month study period to increase awareness of web-based interventions for services and practitioners, encouraging them to inform service users of a range of support options including web-based support. This will contribute to immediate benefits to service users. The study will also provide immediate feasibility information that will produce guidelines for disseminating web-based interventions, and will inform a future definitive trial.