Given the increased risk of mental health problems among children whose parents suffer from mental disorders (Kato et al., 2015; Siegenthaler et al., 2012; Thomason et al., 2014), multiple psychotherapeutic interventions have been carried out in the prevention framework (Tapias et al., 2021). In this sense, the present study has focused on the KidsTime workshops, the first objective being to investigate whether there were differences in the clinical scales of patients and relatives before and after the intervention. Thus, taking into account the joint results of patients and relatives, a significant improvement was observed after the end of the program in two aspects related to parenting; the expression of affection and involvement. Expression of affection includes those behaviors (such as physical proximity, caresses, games, or verbalizations of affection) that foster support directly or indirectly (Aguirre Forero, 2010). Both affection and involvement in parenting form part of the "affective support" dimension of the Parenting Patterns Inventory, and both promote self-esteem and resilience in children (Aguirre Forero, 2010; Iglesias & Triñanes, 2009). In this sense, parents can encourage their children to develop a positive self-image, which would allow them to trust their abilities when they face different difficulties and to be able to express what they think and feel (Aguirre, 2010). Therefore, it can be affirmed that KidsTime, which aims to address and reinforce parenting skills by dedicating a special space for them, is effective in fostering affective support for children. No differences were observed after the intervention in the other two subscales of this dimension ("positive orientation" and "caring practices"), however in both pre-test scores already indicated high affective support at this level. On the other hand, no changes in behavioral regulation, as measured by the subscales "sensitization" and "induction" of the CPI, have been observed. However, it is considered that pre-test measures of these subscales already indicated very adequate strategies on the part of parents to regulate their children's behavior, as the values of practices based on guiding children by explaining the consequences of behavior were very high, while direct applications of corporal or psychological punishments were rare. Therefore, the current data suggest that KidsTime provides improved affective support for parents and could validate and reinforce the behaviors they already use to modify, guide, and facilitate understanding of their children's behavior. Thus, taking into account the changes obtained in the expression of affection and involvement in parenting, and not forgetting the high pre-intervention scores in the other aspects of affective support and behavior regulation, we can think that to the extent that the workshop returns and reinforces these results to the parents, it will increase their confidence in their own parenting skills and in their ability to promote resilience in their children. In turn, this increased self-confidence and empowerment could reduce the likelihood of role reversal, along the lines of other similar programs (Renneberg & Rosenbach, 2016).
The SDQ was used to assess emotional symptoms, behavioral problems, hyperactivity, relationship problems, and prosocial behavior of the sons and daughters, based on information from the parents. The pre-test mean scores are slightly elevated in all subscales, except for prosocial behavior, which would indicate probable significant clinical symptomatology. These data are in line with the higher prevalence of internalising or externalising symptoms reported by other studies for COPMI (Kato et al., 2015; Thomason et al., 2014). Although pre-test scores on prosocial behavior did not indicate significant difficulties at this level, after the intervention, greater prosociality was observed. In the first place, it is considered that this greater capacity to understand the emotions of others and to support them may be due to the multiple activities carried out in the workshops within the framework of emotions (both in identification and in the expression and regulation of these emotions). In addition, prosociality has been related to parental empathy (de Minzi et al., 2011), being a construct that may be closely related to the affective support fostered.
On the other hand, the self-stigma of the people linked to the Mental Health Centre who attended the group was measured. The difference between the pre-test and post-test scores shows that the KidsTime workshops clearly decrease stigma in these people. Previous research has already demonstrated the effectiveness of multi-family interventions in reducing self-stigma and social isolation (Bell et al., 2019; Campbell et al., 2021; Siegenthaler et al., 2012; Tapias et al., 2021; Wolpert et al., 2015). Thus, we consider that KidsTime offers a space directly dedicated to talking about mental health, to clarify information that demystifies mental disorders, to promote that they can talk about their difficulties with their children, but it is also a space in which they are made aware of their abilities and parenting skills beyond the diagnosis. All of this could be related to the resulting decrease in stigma for parents. However, we highlight the benefits that this approach can also have on children, as reducing parental stigma reduces the likelihood of future mental health problems in children and builds resilience (Bishop et al., 2002; Mueller et al., 2016; van Santvoort et al., 2014).
As for measures of parental resilience and self-esteem, no changes have been observed after the intervention. The second and last objective of this study was to establish the degree of satisfaction of the participants with the workshops. Thus, there is a high level of satisfaction, given that 96.5% feel that they have been useful and 97% intend to attend the next workshop. This occurs in both adults and children, which we understand may facilitate adherence to treatment in a population that, due to the characteristics of severe mental disorders, may have difficulties in doing so. The activities are the strong points of the workshop that the children value the most, probably because of the games and dramatizations they include.
This point should be highlighted, since while the playful component has not been considered essential in other types of interventions (Tapias et al., 2021), it can be the most facilitator of assistance in the case of boys and girls.
We likewise believe that the fact that in their childhood they received treatment with which they were satisfied will increase the likelihood that they will have access to mental health services in the future if they need them. Concerning adults, it is the space for emotional expression that is most highlighted by them. On the other hand, it is objectified that KidsTime provides knowledge about mental health to both children and adults, given that 75% explicitly feel that they have learnt aspects they did not know about. In this sense, we can positively value the psycho-educational component of this type of intervention. Finally, we can affirm that this intervention makes parents feel more comfortable talking about mental health with their family, as 78% feel that the workshops will help them to express themselves in this sense. We understand that this may be related to the decrease in self-stigma also observed in this study, which may reduce the fears present in these children concerning parental mental illness.
Future research might assess whether the intervention reduces these fears, as well as assessing and demonstrating children's resilience, KidsTime´s main objective being to promote this capacity. However, the results shown throughout this study are considered to provide indirect evidence of this likely promotion of resilience.
In conclusion, the KidsTime intervention can enhance some protective factors against the increased risk of mental health problems among children of parents with mental illness, as well as reduce risk factors. In this sense, it is effective in improving the affective support of parents towards their children, which could reduce the risk of role reversal and promote self-esteem and resilience in children. Similarly, after the intervention, children's prosocial behavior improves and patients' self-stigma is reduced, the latter being related to a reduction in the likelihood of suffering mental health problems. Given these results and taking into account the aspects most valued by those attending the workshops, we consider that in these families it is especially important to work from a multi-family approach in which psychoeducation is provided, parental skills are worked on and it is carried out in a playful way that facilitates the attendance of the children at the sessions.
Strengths and limitations
This study shows favorable results regarding the effectiveness of psychotherapeutic intervention within the framework of prevention with families in which there is a parent with mental health problems. There are few previous interventions in which the aim is to promote resilience in children through a multidisciplinary, playful, psychoeducational approach that works also on parenting skills (Tapias et al., 2021). Likewise, this study confirms the participants' satisfaction with this type of workshop and identifies both those aspects that are most beneficial to them and those aspects that need to be improved.
However, there are some limitations to the study. Firstly, the size of the sample. Secondly, the fact that being a clinical program, there was no control group. Finally, measures of other variables that could be interesting to assess in children, such as resilience, self-esteem, or stigma, were not collected.