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Priorities for support in mothers of adolescents in residential treatment
Children and Youth Services Review 110 (2020) 104805
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Children and Youth Services Review journal homepage: www.elsevier.com/locate/childyouth
Priorities for support in mothers of adolescents in residential treatment a,⁎
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Kayla Herbell , Anthony J. Banks , Tina Bloom , Yang Li , Linda F.C. Bullock
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The Ohio State University College of Nursing, 1585 Neil Ave, Columbus, OH, 43210, United States University of Missouri School of Social Work, Columbia, MO 65211, United States University of Missouri S235 School of Nursing, University of Missouri, Columbia, MO 65211, United States d University of Virginia School of Nursing, 225 Jeanette Lancaster Way, Charlottesville, VA 22903, United States b c
A R T I C LE I N FO
A B S T R A C T
Keywords: Intimate partner violence Parenting Mental health
Background/Purpose: Mothers of adolescents in residential treatment (RT) experience the highest rates of intimate partner violence (IPV; emotional, physical, and/or sexual abuse by a partner or ex-partner) in the child welfare system. Few studies have investigated the intersection of IPV and parenting in the context of RT. The purpose of this study was to: a) to understand how mothers’ past trauma experiences (i.e. IPV) influence their caregiving, well-being, and relationships with adolescents in RT; b) to explore supportive services mothers need to enhance their well-being before, during, and after their adolescent was in RT. Methods: This cross-sectional study consisted of 15 mothers of adolescents currently or previously in RT. Participants were recruited via Facebook and completed one hour semi-structure interviews over the phone. Data were analyzed by two investigators using content analysis. Results: The following themes emerged from the interviews: “different from the other kids”, “when she goes into a rage her eyes are black…they do remind me of her dad”, and “by supporting the parents, you are supporting the child.”. Women reported stigmatization and disempowerment and coped by compartmentalizing the multiple traumas they sustained from caregiving as well as in their personal lives (i.e., IPV). All women reported that they regularly shared their stories with others in online support groups. Conclusion: Mothers of children in RT are an understudied and underserved population. Supportive, online interventions for this population to share their experiences is critical to maintaining their health.
1. Introduction Mental and behavioral health problems have now surpassed physical health problems in America’s youth (Child Mind Institute, 2015; Merikangas et al., 2010; 2011). Specifically, adolescents with undertreated or untreated mental and behavioral health issues are at a heightened risk for adverse social and health outcomes, including academic failure (McLeod, Uemura, & Rohrman, 2012), substance abuse (Winstanley, Steinwachs, Stitzer, & Fishman, 2012), and arrests (Underwood & Washington, 2016). In an attempt to treat the mental health or behavioral problem and reduce the risk of adverse outcomes for these adolescents, they are referred to a variety of out-of-home treatment settings with varying levels of permanency such as therapeutic foster care, groups homes, or residential treatment (RT) (Mallett & Boitel, 2016). Adolescents in RT and their caregivers, who are most often their mothers (Javalkar et al., 2017; Meltzer, Ford, Goodman, & Vostanis, 2011), are a particularly marginalized and understudied subset of
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families. There is some evidence that these mothers experience a higher frequency and intensity of trauma as compared to the general population (Briggs et al., 2012). Other researchers have substantiated that mothers of children and adolescents in RT experience high rates of intimate partner violence (IPV) (Hussey, 2006; Hussey & Guo, 2002) defined as the emotional, physical, sexual, or verbal abuse by a former or current partner (Breiding, Basile, Smith, Black, & Mahendra, 2015; Breiding et al., 2014). The evidence of the effects of IPV on women is well established, including physical injuries such as fractures, sexually transmitted diseases, chronic pain, and psychological consequences like depression, antisocial behavior, and self-harm (Campbell et al., 2002). A growing body of literature also demonstrates that IPV has lasting effects on adolescent development (Babcock Fenerci & DePrince, 2018; Greeson et al., 2014). Witnessing IPV or living in a home where IPV occurs can lead to impaired emotional regulation (Harding, Morelen, & Thomassin, 2012; Katz, Hunter, & Klowden, 2008), a primary symptom of several mental and behavioral health disorders (e.g., attention deficit
Corresponding author at: The Ohio State University, Martha S. Pitzer Center for Women, Children, and Youth, 1585 Neil Ave, Columbus, OH 43210, United States E-mail address: [email protected] (K. Herbell).
https://doi.org/10.1016/j.childyouth.2020.104805 Received 25 September 2019; Received in revised form 24 January 2020; Accepted 24 January 2020 Available online 25 January 2020 0190-7409/ Published by Elsevier Ltd.
Children and Youth Services Review 110 (2020) 104805
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1.1.3. Recruitment The University Institutional Review Board approved this study (IRB), and all participants provided informed consent. After IRB approval, the study team created a Facebook page containing all relevant study information (e.g., purpose, eligibility criteria, contact information). Two methods of social media recruitment were implemented in this study: flyer postings in private groups and paid advertising on Facebook. First, the study team searched for private Facebook groups that were designed for parents of children and adolescents with mental health or behavioral health disorders. A member of the study team then privately messaged the Facebook group moderator to seek permission to post information about the research study in the private group. Second, the study team created an advertisement that would be viewed by potential participants who met the eligibility criteria created by the study team using Facebook’s advertisement algorithm (e.g., had a Facebook “interest” in ADHD).
hyperactivity disorder, oppositional defiant disorder) that can require RT. Mothers of adolescents in RT experience a unique treatment trajectory referred to as the revolving door phenomena, which in and of itself may be traumatic (Simila, Hakko, Riipinen, & Riala, 2018). In the revolving door phenomena, the adolescent’s mental health symptomology and physical residence alternate from unwell and in RT to well and in the community (Simila et al., 2018). The average length of stay for youth in RT is approximately eight months; however, 54% of children and adolescents in RT stay between one to five years (USDHHS, 2016). Most commonly, treatment plans are client-centered and include strategies to improve medication adherence, substance use education and necessary steps to transition to the next level of care. While there is great variation in RT care models, family involvement can be limited to attending social events, periodic phone calls, home passes, and the family attending therapy sessions with the adolescent (Brown et al., 2010) with little emphasis or intervention for the family who will resume the full caregiving duties when the adolescent is discharged from RT. While adolescents in RT often remain in treatment for a more extended amount of time as compared to other treatment settings (USDHHS, 2016), the majority of RT treatment plans have the goal of reunifying the adolescents with their parent or caregiver upon discharge (Sternberg et al., 2013). This reunification plan emphasizes the importance of understanding the mothers’ experiences and perspectives related to their own traumatic experiences (e.g., IPV) as well as caregiving experiences that may impact differential treatment outcomes for the adolescent and the mother. Therefore, the purpose of this study was twofold: a) to understand how mothers’ past trauma experiences (i.e., IPV) influence their caregiving abilities, well-being, and relationships with adolescents in RT; b) to explore what factors, supportive services, or actions mothers need to enhance their well-being before, during, and after their adolescent entered RT.
1.1.4. Data collection Interested participants were directed on the study flyer to call the study team to determine eligibility. The target sample was recruited over two weeks consisting of 15 participants. During the interviews, women were queried about how their experiences with trauma influenced their caregiving and relationship with their adolescent in RT. The interviewers also asked women about resources and supportive services for their adolescent and themselves before they entered RT, during their RT stay, and after discharge from RT. The study interviews lasted approximately sixty minutes, and participants were compensated with a $25 e-gift card for their time. 1.1.5. Data analysis The data in this study were analyzed using qualitative content analysis as described by Hsieh and Shannon (2005). Content analysis is appropriate when there is limited research regarding the phenomena of interest (Hsieh & Shannon, 2005). First, a semi-structured interview guide consisting of open-ended questions was developed to guide all interviews. Open-ended questions and probes were used in the interviews to elicit more information as needed. Interviews were audio-recorded and transcribed verbatim and reviewed for accuracy by two members of the research team. The data were organized and analyzed in NVIVO 12 (NVivo, 2018). The sample size (N = 15) was determined by data saturation, meaning the analysis and sampling continued until a deep understanding of the phenomena was obtained, and themes were replicated across participants (Morse, 2015). The data analysis described here was independently conducted by two investigators who compared their findings and ultimately reached a consensus on the final themes. First, interview transcripts were read and re-read in their entirety by two team members of the research team to immerse themselves in the interview content for each participant. Next, specific words in the transcripts were highlighted that captured key concepts. Each sentence was assigned a code that was derived from the content in the text (Miles & Huberman, 1994). Codes were “in vivo,” meaning they were often words used directly by the women, such as “different from the other kids,” and “freaked out,” without any attempt to assign meaning or suggest an abstract interpretation. Next, the team members participated in a reflective commentary process in which initial impressions of the data and potential linkages amongst concepts were identified in a written log. The reflective commentary process guided the coding scheme. The codes were then organized into categories based on the linkages within the data. For example, the following codes were collapsed into the category “services specific to mothers' well-being are needed”: “always about my child,” “are you okay,” “it impacts you too,” and “need help.” Next, the categories were defined and organized into themes through a process of reading and re-reading multiple codes together to identify linkages, contrasting meanings, and relative
1.1. Methods 1.1.1. Design and sample This cross-sectional study consisted of qualitative interviews from (N = 15) participants. To be eligible, participants identified as a woman over the age of 18, spoke English, resided in the United States, and had an adolescent between the ages of 10 and 19 who resided in RT. For this study, RT was defined as a facility that “houses youth with significant psychiatric, psychological, or behavioral disorders who have been unsuccessful in outpatient treatment or have proved too ill or unruly to be housed in foster care, day treatment programs, and other nonsecure environments but who do not yet merit commitment to a psychiatric hospital or secure correctional facility” (Office of Juvenile Justice and Delinquency Prevention, 2009). An additional eligibility criterion was a positive screening for IPV exposure during their adolescent’s lifetime, as determined by the Abuse Assessment Screen (AAS) (Soeken, McFarlane, Parker, & Lominack, 1998). The AAS consisted of five items that assessed the frequency and type of IPV exposure (i.e., physical, emotional, verbal, or sexual abuse or neglect by a former or current partner). If any of the questions on the AAS were answered affirmatively, the AAS screen was considered positive for IPV, and the participant was eligible to participate. 1.1.2. Setting Participant recruitment occurred using Facebook, and study interviews occurred at one-time point over the phone. Participants were recruited through Facebook because of the potential to recruit a diverse array of participants who differ demographically (e.g., income, race) and in experiences (Herbell, 2019; Herbell & Zauszniewski, 2018). Only Facebook users that lived in the United States were sampled because the target population consisted of mothers in the United States as RT in different countries differs significantly than RT in the United States. 2
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Table 1 Summary of themes, subthemes, and exemplar quotes. Theme “Different from the other kids.” “When she goes into a rage, her eyes are black, …they do remind me of her dad.”
“By supporting the parents, you are supporting the child.”
Subthemes
Exemplars
Mothers’ experiences of past trauma. The influence of trauma experiences on caregiving
Services specific to mothers' wellbeing are needed. A parent support group is helpful A support group is desired but lacking
importance to the overall understandings of the themes (Hsieh & Shannon, 2005). This process resulted in three themes presented in the analysis below. Please see Table 1 for a summary of themes, subthemes, and exemplar quotes. Trustworthiness was addressed in several ways in this study. First, several study team members created the interview guide. Team members had diverse expertise in both IPV as well as family health in out-ofhome care settings. Second, the study team analyzing the data kept a reflective commentary log (Miles & Huberman, 1994) to record insights and interrelationships among the data. The purpose of the reflective commentary log was to acknowledge biases and record initial impressions as well as patterns as they emerged in the data (Guba & Lincoln, 1989; Shenton, 2004). Third, the interviews contained “member checks” (Guba & Lincoln, 1989) in which after the interview, the interviewer summarized the content of the interview with the participant to verify the accuracy of the content.
“sick, but not in [their] belly, in [their] head.” “beatings in the name of God.” “take anything [they] shared and use it against [them]” “signs that aren't there, but I can't explain to anybody why I see those signs. But they are so real to me.” “oftentimes a lot of her behaviors would trigger me… it heightens how scary it was for me because I lived it” “It was always about [my child]” “How's everything at home? Are you guys functioning okay? Do you need services? What kind of services would benefit you?” “I felt like I was connected to people who had similar stories that were also dealing with their own family crises and just to know that you're not alone.“ “You see a mirror of your own emotions and another parent, and it's not the place, and it's not the time.“
Table 2 Participant Demographics (N = 15). Variable Mother Age 29–40 41–50 51–64 Mother Race/Ethnicity Black Hispanic White Mother Education High school or less Some college Bachelors degree Masters degree IPV Type All Emotional & verbal Physical & emotional Physical & verbal Physical Sexual
1.2. Results 1.2.1. Demographics of the sample The average age of the participants was 43 years old (M = 42.9, SD = 8.2), and the majority of participants were white (n = 11) with at least some college education (n = 13). The most common type of IPV experienced was physical and some other form of abuse (e.g., emotional or verbal) (n = 6). Adolescents in RT were an average of 15 years old (M = 14.6, SD = 2.3), female (n = 9), and had been to RT at least once (M = 1.6, SD = 0.74), with the majority of adolescents residing in RT for less than six months (n = 7). See Table 2 for complete demographic information.
n (%)
5 (33.3) 8 (53.3) 2 (13.3) 1 (6.7) 3 (20) 11 (73.3) 2 5 6 2
(13.3) (33.3) (40) (13.3)
1 5 2 3 1 3
(6.7) (33.3) (13.3) (20) (6.7) (20)
Variable Child Age 11–13 14–16 17–19 Child Gender Female Male
n (%)
4 (26.7) 9 (60) 2 (13.3) 9 (60) 6 (40)
Number of times in RT 1 2 3
8 (53.3) 5 (33.3) 2 (13.3)
Length of stay Less than 6 months 6–12 months 13–24 months More than 24 months
7 3 3 2
(46.7) (20) (20) (13.3)
who requires RT. Women described their journey as “like losing a child” or an inability “to get better from this.“ Women worried that their relationship with their child might never be repaired and remain ”broken“ due to some of the harmful behaviors that their child had exhibited and the likelihood that their child will require intensive psychiatric care for the remainder of their lives.
1.3. Theme 1: “different from the other kids.”
1.4. Theme 2:“ when she goes into a rage, her eyes are black…they do remind me of her dad.”
Mothers described in incredible detail their chaotic home environment while raising a child with severe mental health or behavioral problems. Mothers’ lives were rife with school suspensions, court appearances, suicide attempts, manipulation, violence, and homicidal ideations, running away, as well as managing eating disorders, personality disorders, schizophrenia, illicit drug use, and promiscuity. They described knowing that their child was “different from the other kids” at a young age. One woman reminisced that, even in kindergarten, her daughter was in trouble for “wanting to bomb the school,” while other women described the several suicide attempts their children made over the years, including “jumping out of a 29-foot window.” Still, other mothers described the worry and heartache of realizing their child was severely mentally ill at a young age and trying to educate their child that they are “sick, but not in [their] belly, in [their] head.” Thus, several women described a tremendous sense of loss and sorrow when speaking about their journey with having a child
1.4.1. Mothers’ experiences of past trauma In addition to their parenting demands, women were also trying to heal from their experiences of IPV. Most women were very open about their experiences with IPV. However, many women had difficulty talking about themselves and often strayed to talking about their child's care even though several acknowledged that “self-care is so important…we need to take care of [ourselves] as humans first.” Even though women were only queried about their experiences with IPV, many women also brought up aspects of their childhood that were traumatic. Women reported instances of physical and “insane emotional cruelty” by parents, including one woman who reported that because she did not “have perfect vacuum lines in the carpet,” that her own mother “grabbed a two-by-four and started swinging it.” Other women described “beatings in the name of God,” incest and sexual abuse, and homelessness. One woman reported that her stepfather sexually abused her for the majority of her life, and her mother did not believe that the 3
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What kind of services would benefit you?” Several other women agreed with this sentiment, and when asked if they would have been receptive to being asked about IPV, they said, “I would have been open about it because I know that it impacts…you and your children.”
abuse was occurring. As a result, the woman was sent to RT herself and various group homes five times. The woman summed up the experience by saying she was “fifteen, homeless, and pregnant for a year.” A few women reported a lack of guidance from their parents, and a few were emancipated or estranged from their parents as adults. According to some of the women, the unhealthy relationship with their parents led them to seek solace with their abusive partners and expartners. Women told stories about physical, emotional, and sexual abuse by former and current partners, and they also described being naïve about their partners’ drug use, extramarital affairs, and always feeling “on edge.” Several women described their partners “gaslighting” them and therefore described various instances where their partner would “make [them] doubt [themselves]” or “make [them] feel like [they] were the crazy one” or “take anything [they] shared and use it against [them].” Only one woman reported ever going to a shelter to seek services, and even then, she only “stayed for a few hours.” Notably, 100% of women in this study stated that they would have preferred to be screened and offered services for their IPV exposure; however, most women stated that they were never asked about IPV or other traumatic experiences. Many women described isolation from others as an element of their abuse and that their partner would keep their lives “under lock and key.” Because of this lack of support, many women described staying with their partner despite the abuse for fear of an unfair custody arrangement. One woman regretted not ending the relationship sooner because staying did “one, two, three more years damage, but at the time, you think it is the right decision.”
1.5.2. A parent support group is helpful Women were most often supported by RT with “pamphlets and things,” “pats on the back,” and family counseling. Only two women reported that they had a support group built into the RT that their child resided. One woman who attended the parent support group shared that it “has been like the best thing ever, just to have other parents that kind of get it, and you know that are in the same situation. So, when I found out about the parent support group, that to me was like one of the biggest pros that they have.” Another woman who attended the parent support group said, “I felt like I was connected to people who had similar stories that were also dealing with their own family crises,” and noted that it was beneficial, “just to know that you’re not alone.”Bonding over difficult situations proved to be useful for some women, as one woman revealed that she met her best friend at a counseling seminar. She said, “We always say during the worst time in our lives something good came out of it now, and we became friends.” Women were asked if they would have been receptive to a support group for women like them, and they had an overwhelmingly positive response. Women reported that support groups could have been helpful in coping with this challenging situation. When asked what one thing would have helped them with their journey, all 15 women stated a support group. Ideally, this support group would have “somebody to hold our hand through this process a little bit and help us because it was like we had no idea what to do.” Women reported that they wanted to feel informed about their child's diagnosis and “what to expect after eighteen.” Women also reported that they wanted to know about resources, all of their treatment options, and a “hand to hold” during the challenging transition from RT to home. Several women said that, while child-centric care in RT is necessary, the entire family needs to seek professional help to cope. For example, “when your kids go into some kind of form of mental health care when they're to the point where my son is, it's all about treating the child and the families are left out in the cold, and sometimes they aren't even really included in the treatment.” Several other women echoed the message that a healthy mother means a healthy child: “if you don't stay healthy, if your mind body and soul are not healthy, how can you care for your child”; “in order to take care of the child that's sick, you have to take care of the families, because the family supports the child which in turn helps a child cope.”
1.4.2. The influence of trauma experiences on caregiving Women said that specific characteristics of their child often reminded them of aspects of their childhood or aspects of their relationship with their ex-partner. For example, one woman who ran away as a child reported that she “freaked out” when her child ”whose been going through some anger and rebellion…packed a whole bunch of apples“ to take to school. In reality, the child was bringing food to a struggling family. The woman reported that she overreacted to this behavior because she ”sees signs that aren't there, but I can't explain to anybody why I see those signs. But they are so real to me.“ When asked if certain aspects of the child's behaviors are triggering, another woman made the connection that her ex-partner and the father of her child had never been emotionally present for her as a partner or as a father. Several women reported they were reminded of their partner when their children acted out. One woman described that when her child goes into a rage that, ”there is no stopping her. And it's kind of one of those things that it takes you back to a point in time where you don't need to be, and then you're both in an emotionally unstable moment.“ Similarly, other women recounted that, while perhaps not diagnosed or treated, their partners were likely mentally ill. One woman said, ”my son makes a lot of the same behavior as his dad did,“ while another woman said that hearing about her daughter’s promiscuity reminds her of past abuse because ”oftentimes a lot of her behaviors would trigger me… it heightens how scary it was for me because I lived it.“
1.5.3. A support group is desired but lacking This sample of women also described a desire and need to support one another, “so no one else has to feel the way I feel.” One woman said that if she had unlimited resources, she would “open up a motel for women to come in and out anytime they want.” Other women described learning from their child's situation and wanted to help others: “I really approach this as we have to find the light in this….how can you help somebody else?” Women described that their family lives and the mental health system keeps families isolated from one another. One woman said, “you lock eyes with another parent and you feel the pain, and you feel you can you can see it. It's hard to explain. You see a mirror of your own emotions in another parent, and it's not the place, and it's not the time.” To fill this need, some women volunteered for the National Alliance for Mental Illness while the majority looked to social media to fill the void of support. A few women reported difficulty finding online support groups for parents of children with specific conditions, while other women reported experimenting with different support groups. While some groups were too “overwhelming” or combative, the vast majority of women reported positive experiences using online support groups. Women described that online support is a place to “vent” and “share resources” while others report that “it gives you the chance to say what you really feel without someone going how
1.5. Theme 3: “by supporting the parents, you are supporting the child.” 1.5.1. Services specific to mothers’ own well-being are needed Women provided detailed feedback about aspects of their RT experiences and personal lives that could be enhanced with support. As for RT settings inquiring about IPV or other traumatic experiences, many RT settings assessed but did not provide services or help when a positive screening was detected. When asked if RT inquired about IPV, women said things like: “no, I mean it was always about [my child].” Alternatively, one woman shared that it was like the RT was “collecting data about bio dad and also just how it affected my son.” One woman expressed a strong desire to have had a different experience and described the questions she should have been asked like, “How's everything at home? Are you guys functioning okay? Do you need services? 4
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could you say that?” and it is a place to “hear what’s happening to someone else…it makes you not feel so crazy.”
providers and staff at the RT, presenting a multitude of opportunities for IPV screening. However, to date, there are no clinical guidelines or recommendations for screening for IPV in RT despite the known deleterious consequences of RT on caregiver and child health (Babcock Fenerci & DePrince, 2018; Breiding, Smith, Basile, Walters, Chen, & Merrick, 2014; Breiding et al., 2015; Greeson et al., 2014). Furthermore, mothers mentioned that certain behaviors their adolescent exhibited reminded them of unpleasant and traumatic experiences from their own past. There appears to be a need for parent education in RT about the signs and symptoms of different mental illnesses. Mothers also mentioned a lack of skills to manage their adolescent’s escalating behaviors when they return home. There is a dearth of research into the parenting strategies and practices of mothers of adolescents in RT, and this population may also benefit from interventions such as parenting training to enhance the mother’s parenting efficacy as well as maintain the adolescent’s mental well-being (Baumel, Pawar, Kane, & Correll, 2016). Overall support for mothers of adolescents in RT is severely limited. There were a few participants who reported that there are caregiver support groups built into the RT that their adolescent was in; however, this was a minority of participants. Furthermore, the overwhelming majority of participants believed that a caregiver support group in RT would be beneficial to caregiver mental health by facilitating social connectedness and encouraging self-care. Integrating support groups into RT may not only aid with feelings of isolation and loneliness but also serve as wraparound care for the entire family, which may lend itself to better long-term outcomes for families in RT. Due to the lack of formal supports in place in RT, mothers reported that they used social media to connect with other parents. While the format and content of social media groups varied significantly, social media as delivery for support interventions appeared to be well-liked by this sample of mothers.
1.6. Discussion The purpose of this study was to understand from mothers’ perspectives how traumatic experiences (i.e., IPV) influenced providing care to adolescents in RT as well as to explore the factors, supportive services, or actions needed to enhance the well-being of mothers. To address the purpose of this study, three major themes emerged throughout the 15 qualitative interviews. The first theme describes the home environment in which the mother provides care to her adolescent. Mothers described their adolescent’s internalizing and externalizing behaviors that resulted in the adolescent initially and continually needing RT, such as homicidal ideation, suicide attempts, and other unsafe behaviors in the home. In speaking to mothers, there was an incredible sense of despair when they spoke of “grieving the loss” of their child when their adolescent would yet again be admitted to RT. Depressive symptoms are common in caregiving populations as the demands of caregiving are exhaustive, time-consuming, and emotional (Easter, Sharpe, & Hunt, 2015; Kuriakose, Khan, Almeida, & Braich, 2017; Loh, Tan, Zhang, & Ho, 2017). While we did not specifically ask about depressive symptoms in our study, symptoms of depression were evident in speaking with these mothers, namely hopelessness, guilt, and fatigue. Our findings are in congruence with other studies examining emotional distress and mental health sequelae in caregivers of youth in RT (Buchbinder & BareqetMoshe, 2011; Patel, Head, Dwyer, & Prevde, 2018). More research into the severity and frequency of depressive symptoms and other mental health symptoms (anxiety, post-traumatic stress) in this population are needed so appropriate screening, and referral interventions can be developed. Mothers also described compartmentalizing many of their own traumatic experiences to manage their adolescent's mental illness or behavioral issues. Compartmentalizing is an avoidant coping strategy that is common in individuals who are balancing multiple demands and those who are survivors of trauma (Lanius, 2015). While compartmentalizing past experiences serves a protective purpose, avoidant coping styles can lead to the development of adverse health outcomes (Chao, 2011). The general health status of mothers of children and adolescents in RT is mostly unknown, as there are limited studies that examine the chronic health conditions or health behaviors of this population. Studies are warranted that more fully explore the coping strategies employed by mothers of adolescents in RT as well as the health problems that this population of caregivers experiences. It was unexpected that so many of the participants would speak about their childhood trauma in addition to their experiences with IPV since participants were only explicitly queried about IPV. While there is a well-documented relationship between experiencing childhood trauma and IPV later in life (Fulu et al., 2017), there is also evidence that IPV or other trauma occurs in the majority of families in RT (Briggs et al., 2012). Many women described isolation as an element of their abuse in childhood and adulthood. This finding was in line with a study by Kulkarni (2009) that focused on the relational consequences of IPV for adolescent mothers, mothers reported feeling loneliness and isolation as a result of their IPV. Interestingly, mothers also mentioned isolation in regard to caring for their adolescent in RT as there is no infrastructure in place at RTs where parents could speak or support one another. Mothers described the challenge of healing from their own traumatic experiences while sustaining the caregiver role. This sample of mothers all had IPV exposure during their adolescent’s lifetime, with only one woman ever seeking shelter services. Additionally, 100% of participants stated that they would have preferred to have been screened for IPV and offered services during their adolescent’s RT. Many of these mothers had frequent interactions with health care
1.7. Implications for research Mothers of adolescents in RT are an understudied and underserved population of caregivers; thus, these rich qualitative findings have several implications for future research. Mothers of adolescents in RT may have unresolved and untreated reactions to trauma (e.g., IPV, childhood trauma) that may be influencing their caregiving ability, mental and physical well-being, and the relationship with their adolescent. There is a desperate need for more studies that further unpack the interrelationships between mothers’ trauma history, caregiving factors, and mothers’ and adolescents’ mental and physical health in the RT system. These interrelationships must be studied as adolescents in these families are at considerable risk for experiencing lifelong mental health and behavioral problems, legal involvement, substance use and other adverse outcomes (Sternberg et al., 2013). Furthermore, the current RT system is largely child-centric with little emphasis or line of inquiry about the mother who will likely provide care to the adolescent upon discharge. Future studies need to understand better the breadth of trauma associated with being a caregiver, the health consequences, and design interventions that are trauma-informed for the entire family involved in RT. There is also a desperate need for health promotion and coping interventions that are tailored to the needs of mothers of adolescents in RT. This study provides substantiation that this population of caregivers is highly active on social media, so future studies may elect to deliver interventions online. 2. Limitations The findings presented here should be viewed in light of limitations. First, this study included highly vulnerable women who were queried about various aspects of their lives that may be perceived as embarrassing or shameful. Thus, social desirability bias may have influenced some of their answers. Second, conducting cross-sectional interviews 5
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over the phone with limited ability to establish rapport may have also conditioned participants to give more socially acceptable responses. Third, Facebook was the sole recruitment method, and participants were recruited through active support groups for parents of children with mental health disorders. Thus, participants in this study may be classified as help-seeking considering they were actively engaged in a support group. Therefore, there may be distinct differences between women who are actively engaged in an online support group compared to women who are not seeking help. Thus, our findings may not be transferrable to mothers disengaged from support.
United States, 2011. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C.: 2002), 63(8), 1–18. Breiding, M. J., Basile, K. C., Smith, S. G., Black, M. C., & Mahendra, R. (2015). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control. Briggs, E. C., Greeson, J. K. P., Layne, C. M., Fairbank, J. A., Knoverek, A. M., & Pynoos, R. S. (2012). Trauma exposure, psychosocial functioning, and treatment needs of youth in residential care: Preliminary findings from the NCTSN core data set. Journal of Child & Adolescent Trauma, 5(1), 1–15. https://doi.org/10.1080/19361521.2012. 646413. Brown, J. D., Barrett, K., Ireys, H. T., Allen, K., Pires, S. A., & Blau, G. (2010). Familydriven youth-guided practices in residential treatment: Findings from a national survey of residential treatment facilities. Residential Treatment for Children & Youth, 27(3), 149–159. https://doi.org/10.1080/0886571X.2010.500137. Buchbinder, E., & Bareqet-Moshe, O. (2011). Hope and siege: The experiences of parents whose children were placed in residential care. Residential Treatment for Children & Youth, 28, 120–139. Campbell, J., Jones, A. S., Dienemann, J., Kub, J., Schollenberger, J., O’Campo, P., ... Wynne, C. (2002). Intimate partner violence and physical health consequences. Archives of Internal Medicine, 162(10), 1157–1163. https://doi.org/10.1001/archinte. 162.10.1157. Chao, R.c.-L. (2011). Managing stress and maintaining well-being: Social support, problem-focused coping, and avoidant coping. Journal of Counseling & Development, 89(3), 338–348. Child Mind Institute. (2015). Children’s mental health report. Retrieved from: https:// childmind.org/downloads/2015%20Childrens%20Mental%20Health%20Report.pdf. Easter, G., Sharpe, L., & Hunt, C. J. (2015). Systematic review and meta-analysis of anxious and depressive symptoms in caregivers of children with asthma. Journal of Pediatric Psychology, 40(7), 623–632. https://doi.org/10.1093/jpepsy/jsv012. Fulu, E., Miedema, S., Roselli, T., McCook, S., Chan, K. L., ... Haardörfer, R. (2017). Pathways between childhood trauma, intimate partner violence, and harsh parenting: Findings from the UN Multi-country Study on Men and Violence in Asia and the Pacific. The Lancet. Global Health, 5(5), e512–e522. https://doi.org/10.1016/S2214109X(17)30103-1. Greeson, M. R., Kennedy, A. C., Bybee, D. I., Beeble, M., Adams, A. E., & Sullivan, C. (2014). Beyond deficits: Intimate partner violence, maternal parenting, and child behavior over time. American Journal of Community Psychology, 54(1–2), 46–58. https://doi.org/10.1007/s10464-014-9658-y. Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park, Calif: Sage Publications. Harding, H., Morelen, D., & Thomassin, K. (2012). Exposure to maternal- and paternalperpetrated intimate partner violence, emotion regulation, and child outcomes. Journal of Family Violence, 28. https://doi.org/10.1007/s10896-012-9487-4. Herbell, K. (2019). Using Facebook to recruit pregnant women for research. Nursing Research, 68(3), 242–245. Herbell, K., & Zauszniewski, J. A. (2018). Facebook: An effective recruitment strategy with family caregivers. Applied Nursing Research, 41, 1–4. https://doi.org/10.1016/j. apnr.2018.02.004. Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. Hussey, D. L. (2006). Gender differences in young residential treatment children. Residential Treatment for Children & Youth, 24(1–2), 19–34. Hussey, D. L., & Guo, S. (2002). Profile characteristics and behavioral change trajectories of young residential children. Journal of Child and Family Studies, 11(4), 401–410. https://doi.org/10.1023/A:1020927223517. Javalkar, K., Rak, E., Phillips, A., Haberman, C., Ferris, M., & Van Tilburg, M. (2017). Predictors of caregiver burden among mothers of children with chronic conditions. Children, 4(5), https://doi.org/10.3390/children4050039. Katz, L. F., Hunter, E., & Klowden, A. (2008). Intimate partner violence and children’s reaction to peer provocation: The moderating role of emotion coaching. Journal of Family Psychology, 22(4), 614–621. https://doi.org/10.1037/a0012793. Kulkarni, S. J. (2009). The relational consequences of interpersonal violence (IPV) for adolescent mothers. Youth & Society, 41(1), 100–123. Kuriakose, R. K., Khan, Z., Almeida, D. R. P., & Braich, P. S. (2017). Depression and burden among the caregivers of visually impaired patients: A systematic review. International Ophthalmology, 37(3), 767–777. https://doi.org/10.1007/s10792-0160296-2. Lanius, R. A. (2015). Trauma-related dissociation and altered states of consciousness: A call for clinical, treatment, and neuroscience research. European Journal of Psychotraumatology, 6, 27905. https://doi.org/10.3402/ejpt.v6.27905. Loh, A. Z., Tan, J. S., Zhang, M. W., & Ho, R. C. (2017). The global prevalence of anxiety and depressive symptoms among caregivers of stroke survivors. Journal of the American Medical Directors Association, 18(2), 111–116. https://doi.org/10.1016/j. jamda.2016.08.014. Mallett, C. A., & Boitel, C. (2016). From juvenile offender institutions to residential treatment centers: Evidence of the shifting paradigm to improved youth and community outcomes. Journal of Evidence-Informed Social Work, 13(2), 155–164. https:// doi.org/10.1080/23761407.2015.1013367. McLeod, J. D., Uemura, R., & Rohrman, S. (2012). Adolescent mental health, behavior problems, and academic achievement. Journal of Health and Social Behavior, 53(4), 482–497. https://doi.org/10.1177/0022146512462888. Meltzer, H., Ford, T., Goodman, R., & Vostanis, P. (2011). The burden of caring for children with emotional or conduct disorders. International Journal of Family Medicine, 2011, 801203. https://doi.org/10.1155/2011/801203. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., ...
3. Conclusion In a sample of mothers of adolescents in RT, it is clear that this highly traumatized caregiving population has several unmet needs in the current RT system. While there is a limited body of research specific to families in RT, this study depicts a dire need of overall comprehensive care not just for the individual but for the family as a whole. All participants in this study had experienced at least one form of trauma (i.e., IPV, childhood trauma) that seriously impaired their mental health; yet, there are no supports in place in the RT system to support these caregivers’ mental and physical well-being. Mothers indicated that not only would they have been willing to have been screened for IPV and other traumas but that they would have welcomed referrals to services. Mothers also indicated that they had been isolated by their family, their partner, and the RT system. This population of caregivers desperately needs the infrastructure to support one another to maintain their health and sustain the caregiving role. CRediT authorship contribution statement Kayla Herbell: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing - original draft, Visualization, Supervision, Funding acquisition. Anthony J. Banks: Software, Validation, Formal analysis, Investigation, Writing - original draft. Tina Bloom: Conceptualization, Methodology, Writing - original draft. Yang Li: Conceptualization, Methodology, Writing - original draft. Linda F.C. Bullock: Conceptualization, Methodology, Writing - original draft. Declaration of Competing Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Acknowledgement This study was supported by the University of Missouri Sinclair School of Nursing. The authors would like to offer their special thanks to all of the women who participated in the study. The authors would also like to thank Emily Tomusko for her editing expertise. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.childyouth.2020.104805. References Babcock Fenerci, R. L., & DePrince, A. P. (2018). Shame and alienation related to child maltreatment: Links to symptoms across generations. Psychological Trauma: Theory, Research, Practice & Policy, 10(4), 419–426. https://doi.org/10.1037/tra0000332. Baumel, A., Pawar, A., Kane, J. M., & Correll, C. U. (2016). Digital parent training for children with disruptive behaviors: Systematic review and meta-analysis of randomized trials. Journal of Child and Adolescent Psychopharmacology, 26, 740–749. https://doi.org/10.1089/cap.2016.0048. Breiding, M. J., Smith, S. G., Basile, K. C., Walters, M. L., Chen, J., & Merrick, M. T. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization–national intimate partner and sexual violence survey,
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Similä, N., Hakko, H., Riipinen, P., & Riala, K. (2018). Gender specific characteristics of revolving door adolescents in acute psychiatric inpatient care. Child Psychiatry and Human Development, 49(2), 225–233. https://doi.org/10.1007/s10578-017-0744-x. Soeken, K. L., McFarlane, J., Parker, B., & Lominack, M. C. (1998). The Abuse Assessment Screen: A clinical instrument to measure frequency, severity, and perpetrator of abuse against women. In J. C. Campbell (Ed.). Empowering survivors of abuse: Health care for battered women and their children (pp. 195–203). Thousand Oaks, CA: Sage Publications. Sternberg, N., Thompson, R. W., Smith, G., Klee, S., Cubellis, L., Davidowitz, J., ... Schnur, E. (2013). Outcomes in children's residential treatment centers: A National survey 2010. Residential Treatment for Children & Youth, 30(2), 93–118. https://doi.org/10. 1080/0886571X.2013.785221. Underwood, L. A., & Washington, A. (2016). Mental illness and juvenile offenders. International Journal of Environmental Research and Public Health, 13(2), 228. https:// doi.org/10.3390/ijerph13020228. U.S. Department of Health and Human Services, Administration for Children, Youth and Families. The AFCARS Report. Washington, DC: 2016. Retrieved from www.acf.hhs. gov/programs/cb. Winstanley, E. L., Steinwachs, D. M., Stitzer, M. L., & Fishman, M. J. (2012). Adolescent substance abuse and mental health: Problem co-occurrence and access to services. Journal of Child & Adolescent Substance Abuse, 21(4), 310–322. https://doi.org/10. 1080/1067828X.2012.709453.
Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980–989. https://doi.org/10.1016/j.jaac.2010.05.017. Merikangas, K. R., He, J., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., ... Olfson, M. (2011). Service utilization for lifetime mental disorders in U.S. adolescents: Results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 32–45. https://doi.org/ 10.1016/j.jaac.2010.10.006. Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis-An expanded sourcebook. Sage Publications. Morse, J. M. (2015). Data were saturated…. Qualitative Health Research, 25(5), 587–588. https://doi.org/10.1177/1049732315576699. NVivo qualitative data analysis software; QSR International Pty Ltd. Version 12, 2018. Office of Juvenile Justice and Delinquency Prevention. (2009). OJJDP statistical briefing book. Retrieved from. http://www.ojjdp.gov/ojstatbb/crime/JAR_Display. asp?ID=qa05200. Patel, M., Head, S., Dwyer, J., & Preyde, M. (2018). Youth transition home from residential mental health treatment: Caregivers’ perspective. Child & Adolescent Social Work Journal. https://doi.org/10.1007/s10560-018-0572-2. Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(2), 63–75.
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Contents lists available at ScienceDirect
Children and Youth Services Review journal homepage: www.elsevier.com/locate/childyouth
Priorities for support in mothers of adolescents in residential treatment a,⁎
b
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Kayla Herbell , Anthony J. Banks , Tina Bloom , Yang Li , Linda F.C. Bullock
T
d
a
The Ohio State University College of Nursing, 1585 Neil Ave, Columbus, OH, 43210, United States University of Missouri School of Social Work, Columbia, MO 65211, United States University of Missouri S235 School of Nursing, University of Missouri, Columbia, MO 65211, United States d University of Virginia School of Nursing, 225 Jeanette Lancaster Way, Charlottesville, VA 22903, United States b c
A R T I C LE I N FO
A B S T R A C T
Keywords: Intimate partner violence Parenting Mental health
Background/Purpose: Mothers of adolescents in residential treatment (RT) experience the highest rates of intimate partner violence (IPV; emotional, physical, and/or sexual abuse by a partner or ex-partner) in the child welfare system. Few studies have investigated the intersection of IPV and parenting in the context of RT. The purpose of this study was to: a) to understand how mothers’ past trauma experiences (i.e. IPV) influence their caregiving, well-being, and relationships with adolescents in RT; b) to explore supportive services mothers need to enhance their well-being before, during, and after their adolescent was in RT. Methods: This cross-sectional study consisted of 15 mothers of adolescents currently or previously in RT. Participants were recruited via Facebook and completed one hour semi-structure interviews over the phone. Data were analyzed by two investigators using content analysis. Results: The following themes emerged from the interviews: “different from the other kids”, “when she goes into a rage her eyes are black…they do remind me of her dad”, and “by supporting the parents, you are supporting the child.”. Women reported stigmatization and disempowerment and coped by compartmentalizing the multiple traumas they sustained from caregiving as well as in their personal lives (i.e., IPV). All women reported that they regularly shared their stories with others in online support groups. Conclusion: Mothers of children in RT are an understudied and underserved population. Supportive, online interventions for this population to share their experiences is critical to maintaining their health.
1. Introduction Mental and behavioral health problems have now surpassed physical health problems in America’s youth (Child Mind Institute, 2015; Merikangas et al., 2010; 2011). Specifically, adolescents with undertreated or untreated mental and behavioral health issues are at a heightened risk for adverse social and health outcomes, including academic failure (McLeod, Uemura, & Rohrman, 2012), substance abuse (Winstanley, Steinwachs, Stitzer, & Fishman, 2012), and arrests (Underwood & Washington, 2016). In an attempt to treat the mental health or behavioral problem and reduce the risk of adverse outcomes for these adolescents, they are referred to a variety of out-of-home treatment settings with varying levels of permanency such as therapeutic foster care, groups homes, or residential treatment (RT) (Mallett & Boitel, 2016). Adolescents in RT and their caregivers, who are most often their mothers (Javalkar et al., 2017; Meltzer, Ford, Goodman, & Vostanis, 2011), are a particularly marginalized and understudied subset of
⁎
families. There is some evidence that these mothers experience a higher frequency and intensity of trauma as compared to the general population (Briggs et al., 2012). Other researchers have substantiated that mothers of children and adolescents in RT experience high rates of intimate partner violence (IPV) (Hussey, 2006; Hussey & Guo, 2002) defined as the emotional, physical, sexual, or verbal abuse by a former or current partner (Breiding, Basile, Smith, Black, & Mahendra, 2015; Breiding et al., 2014). The evidence of the effects of IPV on women is well established, including physical injuries such as fractures, sexually transmitted diseases, chronic pain, and psychological consequences like depression, antisocial behavior, and self-harm (Campbell et al., 2002). A growing body of literature also demonstrates that IPV has lasting effects on adolescent development (Babcock Fenerci & DePrince, 2018; Greeson et al., 2014). Witnessing IPV or living in a home where IPV occurs can lead to impaired emotional regulation (Harding, Morelen, & Thomassin, 2012; Katz, Hunter, & Klowden, 2008), a primary symptom of several mental and behavioral health disorders (e.g., attention deficit
Corresponding author at: The Ohio State University, Martha S. Pitzer Center for Women, Children, and Youth, 1585 Neil Ave, Columbus, OH 43210, United States E-mail address: [email protected] (K. Herbell).
https://doi.org/10.1016/j.childyouth.2020.104805 Received 25 September 2019; Received in revised form 24 January 2020; Accepted 24 January 2020 Available online 25 January 2020 0190-7409/ Published by Elsevier Ltd.
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1.1.3. Recruitment The University Institutional Review Board approved this study (IRB), and all participants provided informed consent. After IRB approval, the study team created a Facebook page containing all relevant study information (e.g., purpose, eligibility criteria, contact information). Two methods of social media recruitment were implemented in this study: flyer postings in private groups and paid advertising on Facebook. First, the study team searched for private Facebook groups that were designed for parents of children and adolescents with mental health or behavioral health disorders. A member of the study team then privately messaged the Facebook group moderator to seek permission to post information about the research study in the private group. Second, the study team created an advertisement that would be viewed by potential participants who met the eligibility criteria created by the study team using Facebook’s advertisement algorithm (e.g., had a Facebook “interest” in ADHD).
hyperactivity disorder, oppositional defiant disorder) that can require RT. Mothers of adolescents in RT experience a unique treatment trajectory referred to as the revolving door phenomena, which in and of itself may be traumatic (Simila, Hakko, Riipinen, & Riala, 2018). In the revolving door phenomena, the adolescent’s mental health symptomology and physical residence alternate from unwell and in RT to well and in the community (Simila et al., 2018). The average length of stay for youth in RT is approximately eight months; however, 54% of children and adolescents in RT stay between one to five years (USDHHS, 2016). Most commonly, treatment plans are client-centered and include strategies to improve medication adherence, substance use education and necessary steps to transition to the next level of care. While there is great variation in RT care models, family involvement can be limited to attending social events, periodic phone calls, home passes, and the family attending therapy sessions with the adolescent (Brown et al., 2010) with little emphasis or intervention for the family who will resume the full caregiving duties when the adolescent is discharged from RT. While adolescents in RT often remain in treatment for a more extended amount of time as compared to other treatment settings (USDHHS, 2016), the majority of RT treatment plans have the goal of reunifying the adolescents with their parent or caregiver upon discharge (Sternberg et al., 2013). This reunification plan emphasizes the importance of understanding the mothers’ experiences and perspectives related to their own traumatic experiences (e.g., IPV) as well as caregiving experiences that may impact differential treatment outcomes for the adolescent and the mother. Therefore, the purpose of this study was twofold: a) to understand how mothers’ past trauma experiences (i.e., IPV) influence their caregiving abilities, well-being, and relationships with adolescents in RT; b) to explore what factors, supportive services, or actions mothers need to enhance their well-being before, during, and after their adolescent entered RT.
1.1.4. Data collection Interested participants were directed on the study flyer to call the study team to determine eligibility. The target sample was recruited over two weeks consisting of 15 participants. During the interviews, women were queried about how their experiences with trauma influenced their caregiving and relationship with their adolescent in RT. The interviewers also asked women about resources and supportive services for their adolescent and themselves before they entered RT, during their RT stay, and after discharge from RT. The study interviews lasted approximately sixty minutes, and participants were compensated with a $25 e-gift card for their time. 1.1.5. Data analysis The data in this study were analyzed using qualitative content analysis as described by Hsieh and Shannon (2005). Content analysis is appropriate when there is limited research regarding the phenomena of interest (Hsieh & Shannon, 2005). First, a semi-structured interview guide consisting of open-ended questions was developed to guide all interviews. Open-ended questions and probes were used in the interviews to elicit more information as needed. Interviews were audio-recorded and transcribed verbatim and reviewed for accuracy by two members of the research team. The data were organized and analyzed in NVIVO 12 (NVivo, 2018). The sample size (N = 15) was determined by data saturation, meaning the analysis and sampling continued until a deep understanding of the phenomena was obtained, and themes were replicated across participants (Morse, 2015). The data analysis described here was independently conducted by two investigators who compared their findings and ultimately reached a consensus on the final themes. First, interview transcripts were read and re-read in their entirety by two team members of the research team to immerse themselves in the interview content for each participant. Next, specific words in the transcripts were highlighted that captured key concepts. Each sentence was assigned a code that was derived from the content in the text (Miles & Huberman, 1994). Codes were “in vivo,” meaning they were often words used directly by the women, such as “different from the other kids,” and “freaked out,” without any attempt to assign meaning or suggest an abstract interpretation. Next, the team members participated in a reflective commentary process in which initial impressions of the data and potential linkages amongst concepts were identified in a written log. The reflective commentary process guided the coding scheme. The codes were then organized into categories based on the linkages within the data. For example, the following codes were collapsed into the category “services specific to mothers' well-being are needed”: “always about my child,” “are you okay,” “it impacts you too,” and “need help.” Next, the categories were defined and organized into themes through a process of reading and re-reading multiple codes together to identify linkages, contrasting meanings, and relative
1.1. Methods 1.1.1. Design and sample This cross-sectional study consisted of qualitative interviews from (N = 15) participants. To be eligible, participants identified as a woman over the age of 18, spoke English, resided in the United States, and had an adolescent between the ages of 10 and 19 who resided in RT. For this study, RT was defined as a facility that “houses youth with significant psychiatric, psychological, or behavioral disorders who have been unsuccessful in outpatient treatment or have proved too ill or unruly to be housed in foster care, day treatment programs, and other nonsecure environments but who do not yet merit commitment to a psychiatric hospital or secure correctional facility” (Office of Juvenile Justice and Delinquency Prevention, 2009). An additional eligibility criterion was a positive screening for IPV exposure during their adolescent’s lifetime, as determined by the Abuse Assessment Screen (AAS) (Soeken, McFarlane, Parker, & Lominack, 1998). The AAS consisted of five items that assessed the frequency and type of IPV exposure (i.e., physical, emotional, verbal, or sexual abuse or neglect by a former or current partner). If any of the questions on the AAS were answered affirmatively, the AAS screen was considered positive for IPV, and the participant was eligible to participate. 1.1.2. Setting Participant recruitment occurred using Facebook, and study interviews occurred at one-time point over the phone. Participants were recruited through Facebook because of the potential to recruit a diverse array of participants who differ demographically (e.g., income, race) and in experiences (Herbell, 2019; Herbell & Zauszniewski, 2018). Only Facebook users that lived in the United States were sampled because the target population consisted of mothers in the United States as RT in different countries differs significantly than RT in the United States. 2
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Table 1 Summary of themes, subthemes, and exemplar quotes. Theme “Different from the other kids.” “When she goes into a rage, her eyes are black, …they do remind me of her dad.”
“By supporting the parents, you are supporting the child.”
Subthemes
Exemplars
Mothers’ experiences of past trauma. The influence of trauma experiences on caregiving
Services specific to mothers' wellbeing are needed. A parent support group is helpful A support group is desired but lacking
importance to the overall understandings of the themes (Hsieh & Shannon, 2005). This process resulted in three themes presented in the analysis below. Please see Table 1 for a summary of themes, subthemes, and exemplar quotes. Trustworthiness was addressed in several ways in this study. First, several study team members created the interview guide. Team members had diverse expertise in both IPV as well as family health in out-ofhome care settings. Second, the study team analyzing the data kept a reflective commentary log (Miles & Huberman, 1994) to record insights and interrelationships among the data. The purpose of the reflective commentary log was to acknowledge biases and record initial impressions as well as patterns as they emerged in the data (Guba & Lincoln, 1989; Shenton, 2004). Third, the interviews contained “member checks” (Guba & Lincoln, 1989) in which after the interview, the interviewer summarized the content of the interview with the participant to verify the accuracy of the content.
“sick, but not in [their] belly, in [their] head.” “beatings in the name of God.” “take anything [they] shared and use it against [them]” “signs that aren't there, but I can't explain to anybody why I see those signs. But they are so real to me.” “oftentimes a lot of her behaviors would trigger me… it heightens how scary it was for me because I lived it” “It was always about [my child]” “How's everything at home? Are you guys functioning okay? Do you need services? What kind of services would benefit you?” “I felt like I was connected to people who had similar stories that were also dealing with their own family crises and just to know that you're not alone.“ “You see a mirror of your own emotions and another parent, and it's not the place, and it's not the time.“
Table 2 Participant Demographics (N = 15). Variable Mother Age 29–40 41–50 51–64 Mother Race/Ethnicity Black Hispanic White Mother Education High school or less Some college Bachelors degree Masters degree IPV Type All Emotional & verbal Physical & emotional Physical & verbal Physical Sexual
1.2. Results 1.2.1. Demographics of the sample The average age of the participants was 43 years old (M = 42.9, SD = 8.2), and the majority of participants were white (n = 11) with at least some college education (n = 13). The most common type of IPV experienced was physical and some other form of abuse (e.g., emotional or verbal) (n = 6). Adolescents in RT were an average of 15 years old (M = 14.6, SD = 2.3), female (n = 9), and had been to RT at least once (M = 1.6, SD = 0.74), with the majority of adolescents residing in RT for less than six months (n = 7). See Table 2 for complete demographic information.
n (%)
5 (33.3) 8 (53.3) 2 (13.3) 1 (6.7) 3 (20) 11 (73.3) 2 5 6 2
(13.3) (33.3) (40) (13.3)
1 5 2 3 1 3
(6.7) (33.3) (13.3) (20) (6.7) (20)
Variable Child Age 11–13 14–16 17–19 Child Gender Female Male
n (%)
4 (26.7) 9 (60) 2 (13.3) 9 (60) 6 (40)
Number of times in RT 1 2 3
8 (53.3) 5 (33.3) 2 (13.3)
Length of stay Less than 6 months 6–12 months 13–24 months More than 24 months
7 3 3 2
(46.7) (20) (20) (13.3)
who requires RT. Women described their journey as “like losing a child” or an inability “to get better from this.“ Women worried that their relationship with their child might never be repaired and remain ”broken“ due to some of the harmful behaviors that their child had exhibited and the likelihood that their child will require intensive psychiatric care for the remainder of their lives.
1.3. Theme 1: “different from the other kids.”
1.4. Theme 2:“ when she goes into a rage, her eyes are black…they do remind me of her dad.”
Mothers described in incredible detail their chaotic home environment while raising a child with severe mental health or behavioral problems. Mothers’ lives were rife with school suspensions, court appearances, suicide attempts, manipulation, violence, and homicidal ideations, running away, as well as managing eating disorders, personality disorders, schizophrenia, illicit drug use, and promiscuity. They described knowing that their child was “different from the other kids” at a young age. One woman reminisced that, even in kindergarten, her daughter was in trouble for “wanting to bomb the school,” while other women described the several suicide attempts their children made over the years, including “jumping out of a 29-foot window.” Still, other mothers described the worry and heartache of realizing their child was severely mentally ill at a young age and trying to educate their child that they are “sick, but not in [their] belly, in [their] head.” Thus, several women described a tremendous sense of loss and sorrow when speaking about their journey with having a child
1.4.1. Mothers’ experiences of past trauma In addition to their parenting demands, women were also trying to heal from their experiences of IPV. Most women were very open about their experiences with IPV. However, many women had difficulty talking about themselves and often strayed to talking about their child's care even though several acknowledged that “self-care is so important…we need to take care of [ourselves] as humans first.” Even though women were only queried about their experiences with IPV, many women also brought up aspects of their childhood that were traumatic. Women reported instances of physical and “insane emotional cruelty” by parents, including one woman who reported that because she did not “have perfect vacuum lines in the carpet,” that her own mother “grabbed a two-by-four and started swinging it.” Other women described “beatings in the name of God,” incest and sexual abuse, and homelessness. One woman reported that her stepfather sexually abused her for the majority of her life, and her mother did not believe that the 3
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What kind of services would benefit you?” Several other women agreed with this sentiment, and when asked if they would have been receptive to being asked about IPV, they said, “I would have been open about it because I know that it impacts…you and your children.”
abuse was occurring. As a result, the woman was sent to RT herself and various group homes five times. The woman summed up the experience by saying she was “fifteen, homeless, and pregnant for a year.” A few women reported a lack of guidance from their parents, and a few were emancipated or estranged from their parents as adults. According to some of the women, the unhealthy relationship with their parents led them to seek solace with their abusive partners and expartners. Women told stories about physical, emotional, and sexual abuse by former and current partners, and they also described being naïve about their partners’ drug use, extramarital affairs, and always feeling “on edge.” Several women described their partners “gaslighting” them and therefore described various instances where their partner would “make [them] doubt [themselves]” or “make [them] feel like [they] were the crazy one” or “take anything [they] shared and use it against [them].” Only one woman reported ever going to a shelter to seek services, and even then, she only “stayed for a few hours.” Notably, 100% of women in this study stated that they would have preferred to be screened and offered services for their IPV exposure; however, most women stated that they were never asked about IPV or other traumatic experiences. Many women described isolation from others as an element of their abuse and that their partner would keep their lives “under lock and key.” Because of this lack of support, many women described staying with their partner despite the abuse for fear of an unfair custody arrangement. One woman regretted not ending the relationship sooner because staying did “one, two, three more years damage, but at the time, you think it is the right decision.”
1.5.2. A parent support group is helpful Women were most often supported by RT with “pamphlets and things,” “pats on the back,” and family counseling. Only two women reported that they had a support group built into the RT that their child resided. One woman who attended the parent support group shared that it “has been like the best thing ever, just to have other parents that kind of get it, and you know that are in the same situation. So, when I found out about the parent support group, that to me was like one of the biggest pros that they have.” Another woman who attended the parent support group said, “I felt like I was connected to people who had similar stories that were also dealing with their own family crises,” and noted that it was beneficial, “just to know that you’re not alone.”Bonding over difficult situations proved to be useful for some women, as one woman revealed that she met her best friend at a counseling seminar. She said, “We always say during the worst time in our lives something good came out of it now, and we became friends.” Women were asked if they would have been receptive to a support group for women like them, and they had an overwhelmingly positive response. Women reported that support groups could have been helpful in coping with this challenging situation. When asked what one thing would have helped them with their journey, all 15 women stated a support group. Ideally, this support group would have “somebody to hold our hand through this process a little bit and help us because it was like we had no idea what to do.” Women reported that they wanted to feel informed about their child's diagnosis and “what to expect after eighteen.” Women also reported that they wanted to know about resources, all of their treatment options, and a “hand to hold” during the challenging transition from RT to home. Several women said that, while child-centric care in RT is necessary, the entire family needs to seek professional help to cope. For example, “when your kids go into some kind of form of mental health care when they're to the point where my son is, it's all about treating the child and the families are left out in the cold, and sometimes they aren't even really included in the treatment.” Several other women echoed the message that a healthy mother means a healthy child: “if you don't stay healthy, if your mind body and soul are not healthy, how can you care for your child”; “in order to take care of the child that's sick, you have to take care of the families, because the family supports the child which in turn helps a child cope.”
1.4.2. The influence of trauma experiences on caregiving Women said that specific characteristics of their child often reminded them of aspects of their childhood or aspects of their relationship with their ex-partner. For example, one woman who ran away as a child reported that she “freaked out” when her child ”whose been going through some anger and rebellion…packed a whole bunch of apples“ to take to school. In reality, the child was bringing food to a struggling family. The woman reported that she overreacted to this behavior because she ”sees signs that aren't there, but I can't explain to anybody why I see those signs. But they are so real to me.“ When asked if certain aspects of the child's behaviors are triggering, another woman made the connection that her ex-partner and the father of her child had never been emotionally present for her as a partner or as a father. Several women reported they were reminded of their partner when their children acted out. One woman described that when her child goes into a rage that, ”there is no stopping her. And it's kind of one of those things that it takes you back to a point in time where you don't need to be, and then you're both in an emotionally unstable moment.“ Similarly, other women recounted that, while perhaps not diagnosed or treated, their partners were likely mentally ill. One woman said, ”my son makes a lot of the same behavior as his dad did,“ while another woman said that hearing about her daughter’s promiscuity reminds her of past abuse because ”oftentimes a lot of her behaviors would trigger me… it heightens how scary it was for me because I lived it.“
1.5.3. A support group is desired but lacking This sample of women also described a desire and need to support one another, “so no one else has to feel the way I feel.” One woman said that if she had unlimited resources, she would “open up a motel for women to come in and out anytime they want.” Other women described learning from their child's situation and wanted to help others: “I really approach this as we have to find the light in this….how can you help somebody else?” Women described that their family lives and the mental health system keeps families isolated from one another. One woman said, “you lock eyes with another parent and you feel the pain, and you feel you can you can see it. It's hard to explain. You see a mirror of your own emotions in another parent, and it's not the place, and it's not the time.” To fill this need, some women volunteered for the National Alliance for Mental Illness while the majority looked to social media to fill the void of support. A few women reported difficulty finding online support groups for parents of children with specific conditions, while other women reported experimenting with different support groups. While some groups were too “overwhelming” or combative, the vast majority of women reported positive experiences using online support groups. Women described that online support is a place to “vent” and “share resources” while others report that “it gives you the chance to say what you really feel without someone going how
1.5. Theme 3: “by supporting the parents, you are supporting the child.” 1.5.1. Services specific to mothers’ own well-being are needed Women provided detailed feedback about aspects of their RT experiences and personal lives that could be enhanced with support. As for RT settings inquiring about IPV or other traumatic experiences, many RT settings assessed but did not provide services or help when a positive screening was detected. When asked if RT inquired about IPV, women said things like: “no, I mean it was always about [my child].” Alternatively, one woman shared that it was like the RT was “collecting data about bio dad and also just how it affected my son.” One woman expressed a strong desire to have had a different experience and described the questions she should have been asked like, “How's everything at home? Are you guys functioning okay? Do you need services? 4
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could you say that?” and it is a place to “hear what’s happening to someone else…it makes you not feel so crazy.”
providers and staff at the RT, presenting a multitude of opportunities for IPV screening. However, to date, there are no clinical guidelines or recommendations for screening for IPV in RT despite the known deleterious consequences of RT on caregiver and child health (Babcock Fenerci & DePrince, 2018; Breiding, Smith, Basile, Walters, Chen, & Merrick, 2014; Breiding et al., 2015; Greeson et al., 2014). Furthermore, mothers mentioned that certain behaviors their adolescent exhibited reminded them of unpleasant and traumatic experiences from their own past. There appears to be a need for parent education in RT about the signs and symptoms of different mental illnesses. Mothers also mentioned a lack of skills to manage their adolescent’s escalating behaviors when they return home. There is a dearth of research into the parenting strategies and practices of mothers of adolescents in RT, and this population may also benefit from interventions such as parenting training to enhance the mother’s parenting efficacy as well as maintain the adolescent’s mental well-being (Baumel, Pawar, Kane, & Correll, 2016). Overall support for mothers of adolescents in RT is severely limited. There were a few participants who reported that there are caregiver support groups built into the RT that their adolescent was in; however, this was a minority of participants. Furthermore, the overwhelming majority of participants believed that a caregiver support group in RT would be beneficial to caregiver mental health by facilitating social connectedness and encouraging self-care. Integrating support groups into RT may not only aid with feelings of isolation and loneliness but also serve as wraparound care for the entire family, which may lend itself to better long-term outcomes for families in RT. Due to the lack of formal supports in place in RT, mothers reported that they used social media to connect with other parents. While the format and content of social media groups varied significantly, social media as delivery for support interventions appeared to be well-liked by this sample of mothers.
1.6. Discussion The purpose of this study was to understand from mothers’ perspectives how traumatic experiences (i.e., IPV) influenced providing care to adolescents in RT as well as to explore the factors, supportive services, or actions needed to enhance the well-being of mothers. To address the purpose of this study, three major themes emerged throughout the 15 qualitative interviews. The first theme describes the home environment in which the mother provides care to her adolescent. Mothers described their adolescent’s internalizing and externalizing behaviors that resulted in the adolescent initially and continually needing RT, such as homicidal ideation, suicide attempts, and other unsafe behaviors in the home. In speaking to mothers, there was an incredible sense of despair when they spoke of “grieving the loss” of their child when their adolescent would yet again be admitted to RT. Depressive symptoms are common in caregiving populations as the demands of caregiving are exhaustive, time-consuming, and emotional (Easter, Sharpe, & Hunt, 2015; Kuriakose, Khan, Almeida, & Braich, 2017; Loh, Tan, Zhang, & Ho, 2017). While we did not specifically ask about depressive symptoms in our study, symptoms of depression were evident in speaking with these mothers, namely hopelessness, guilt, and fatigue. Our findings are in congruence with other studies examining emotional distress and mental health sequelae in caregivers of youth in RT (Buchbinder & BareqetMoshe, 2011; Patel, Head, Dwyer, & Prevde, 2018). More research into the severity and frequency of depressive symptoms and other mental health symptoms (anxiety, post-traumatic stress) in this population are needed so appropriate screening, and referral interventions can be developed. Mothers also described compartmentalizing many of their own traumatic experiences to manage their adolescent's mental illness or behavioral issues. Compartmentalizing is an avoidant coping strategy that is common in individuals who are balancing multiple demands and those who are survivors of trauma (Lanius, 2015). While compartmentalizing past experiences serves a protective purpose, avoidant coping styles can lead to the development of adverse health outcomes (Chao, 2011). The general health status of mothers of children and adolescents in RT is mostly unknown, as there are limited studies that examine the chronic health conditions or health behaviors of this population. Studies are warranted that more fully explore the coping strategies employed by mothers of adolescents in RT as well as the health problems that this population of caregivers experiences. It was unexpected that so many of the participants would speak about their childhood trauma in addition to their experiences with IPV since participants were only explicitly queried about IPV. While there is a well-documented relationship between experiencing childhood trauma and IPV later in life (Fulu et al., 2017), there is also evidence that IPV or other trauma occurs in the majority of families in RT (Briggs et al., 2012). Many women described isolation as an element of their abuse in childhood and adulthood. This finding was in line with a study by Kulkarni (2009) that focused on the relational consequences of IPV for adolescent mothers, mothers reported feeling loneliness and isolation as a result of their IPV. Interestingly, mothers also mentioned isolation in regard to caring for their adolescent in RT as there is no infrastructure in place at RTs where parents could speak or support one another. Mothers described the challenge of healing from their own traumatic experiences while sustaining the caregiver role. This sample of mothers all had IPV exposure during their adolescent’s lifetime, with only one woman ever seeking shelter services. Additionally, 100% of participants stated that they would have preferred to have been screened for IPV and offered services during their adolescent’s RT. Many of these mothers had frequent interactions with health care
1.7. Implications for research Mothers of adolescents in RT are an understudied and underserved population of caregivers; thus, these rich qualitative findings have several implications for future research. Mothers of adolescents in RT may have unresolved and untreated reactions to trauma (e.g., IPV, childhood trauma) that may be influencing their caregiving ability, mental and physical well-being, and the relationship with their adolescent. There is a desperate need for more studies that further unpack the interrelationships between mothers’ trauma history, caregiving factors, and mothers’ and adolescents’ mental and physical health in the RT system. These interrelationships must be studied as adolescents in these families are at considerable risk for experiencing lifelong mental health and behavioral problems, legal involvement, substance use and other adverse outcomes (Sternberg et al., 2013). Furthermore, the current RT system is largely child-centric with little emphasis or line of inquiry about the mother who will likely provide care to the adolescent upon discharge. Future studies need to understand better the breadth of trauma associated with being a caregiver, the health consequences, and design interventions that are trauma-informed for the entire family involved in RT. There is also a desperate need for health promotion and coping interventions that are tailored to the needs of mothers of adolescents in RT. This study provides substantiation that this population of caregivers is highly active on social media, so future studies may elect to deliver interventions online. 2. Limitations The findings presented here should be viewed in light of limitations. First, this study included highly vulnerable women who were queried about various aspects of their lives that may be perceived as embarrassing or shameful. Thus, social desirability bias may have influenced some of their answers. Second, conducting cross-sectional interviews 5
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over the phone with limited ability to establish rapport may have also conditioned participants to give more socially acceptable responses. Third, Facebook was the sole recruitment method, and participants were recruited through active support groups for parents of children with mental health disorders. Thus, participants in this study may be classified as help-seeking considering they were actively engaged in a support group. Therefore, there may be distinct differences between women who are actively engaged in an online support group compared to women who are not seeking help. Thus, our findings may not be transferrable to mothers disengaged from support.
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3. Conclusion In a sample of mothers of adolescents in RT, it is clear that this highly traumatized caregiving population has several unmet needs in the current RT system. While there is a limited body of research specific to families in RT, this study depicts a dire need of overall comprehensive care not just for the individual but for the family as a whole. All participants in this study had experienced at least one form of trauma (i.e., IPV, childhood trauma) that seriously impaired their mental health; yet, there are no supports in place in the RT system to support these caregivers’ mental and physical well-being. Mothers indicated that not only would they have been willing to have been screened for IPV and other traumas but that they would have welcomed referrals to services. Mothers also indicated that they had been isolated by their family, their partner, and the RT system. This population of caregivers desperately needs the infrastructure to support one another to maintain their health and sustain the caregiving role. CRediT authorship contribution statement Kayla Herbell: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing - original draft, Visualization, Supervision, Funding acquisition. Anthony J. Banks: Software, Validation, Formal analysis, Investigation, Writing - original draft. Tina Bloom: Conceptualization, Methodology, Writing - original draft. Yang Li: Conceptualization, Methodology, Writing - original draft. Linda F.C. Bullock: Conceptualization, Methodology, Writing - original draft. Declaration of Competing Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Acknowledgement This study was supported by the University of Missouri Sinclair School of Nursing. The authors would like to offer their special thanks to all of the women who participated in the study. The authors would also like to thank Emily Tomusko for her editing expertise. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.childyouth.2020.104805. References Babcock Fenerci, R. L., & DePrince, A. P. (2018). Shame and alienation related to child maltreatment: Links to symptoms across generations. Psychological Trauma: Theory, Research, Practice & Policy, 10(4), 419–426. https://doi.org/10.1037/tra0000332. Baumel, A., Pawar, A., Kane, J. M., & Correll, C. U. (2016). Digital parent training for children with disruptive behaviors: Systematic review and meta-analysis of randomized trials. Journal of Child and Adolescent Psychopharmacology, 26, 740–749. https://doi.org/10.1089/cap.2016.0048. Breiding, M. J., Smith, S. G., Basile, K. C., Walters, M. L., Chen, J., & Merrick, M. T. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization–national intimate partner and sexual violence survey,
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