Support for families in protecting the mental health of children

The family can be a background of health crises and – at the same time – the greatest source of support for a child. It plays a crucial role in reducing the risk of disorders and increasing the psychological immunity of teenagers. The article presents a number of threats to the mental health of young people, derived from different research. Its main goal is to present the importance of the support system for parents and families in protection of children's mental health. Against this background, some parental errors and deficiencies are analysed as the reasons for ignoring the first symptoms of a child’s crisis. Support for the youth and their families should be provided not only from parents but also from teachers, pedagogues and their wider social environment. Many institutions, including medical staff, schools, governmental and non-governmental organisations may effectively support parents and caregivers in prevention and intervention in a situation of mental crisis. The article discusses the determinants of effective help for families experiencing mental health crises of children.


Introduction
The number of mental disorders occurring among Polish children and adolescents is still growing and becomes a great challenge for researchers and practitioners. Only some of the children at risk of mental problems get professional help, and the reason is not only the lack of any medical treatment. The worst situation is when psychogenic and environmental factors overlap. Mental health problems are related to other spheres of family life and influence the way a child functions at home and school and in the peer environment. Children without effective social training and an ability to communicate about problems are in a particularly difficult situation when there are no adults who could understand and change the situation. In spite of many alarming data, the public system of medical counselling and treatment is still not working properly.
Facing the global increasing prevalence of child and adolescent disorders, some changes must be launched in psychiatry dedicated to these groups. According to the WHO, World Psychiatric Association and other associations in the field of child mental health, one of the most desired priorities of child and adolescent psychiatry for the next decade is to promote collaboration and mutual education among different professionals who interact with children and families (Skokauskas, Fung, Flathery, von Klitzing, Puras, Servili, Dua, Falissard, Vostanis, Moyano, Feldman, Clark, Boricević, Patton, Leventhal & Guerrero, 2019). Reorienting mental health services requires more preparation and training for allied mental health professionals, like paediatricians, general practitioners, advanced practice nurses as well as teachers and school psychologists. Diverting resources in the mental health care system opens possibilities of taking preventive actions in the family or school environment. Fostering a healthy child and adolescent development and supporting parenting at the environmental level may reduce the burden of psychiatric disorders by enabling access to early recognition and treatment. We should remember that the adverse effects of early life mental disorders may limit productivity, induce social disruption and increase the costs of health and social care.
The presented essay is an review article and may be treated as an introduction to a broader analysis of the support system for families with children with mental health problems in Poland. The aim of the article is to review solutions in the field of prevention and mental health care for children and adolescents in relation to the family. First, the most common threats and complaints of children's mental health will be presented. This part of the article is based on the research of various authors, including (partially) the author's own research conducted in 2017 in Wroclaw (Poland). Important outcomes are brought from helpline reports and studies, highlighting subjective symptoms of mental health disorders such as tiredness and feeling loneliness in everyday life problems. Many children experience somatic and psychological symptoms of stress, but they cannot count on help from adults. The low level of social support is a result of limited parental and communication competences of parents. Cited reports show that young people are sometimes more likely to trust a stranger who offers a conversation as part of online help, reducing the possibility of feeling evaluated or abashed. Unfortunately, parents are not well prepared for many mental crises threatening their children. They should be trained in identifying 'red flags' and distinguishing signs of a mental health problem in normal childhood behaviour.
The most important aim of the article is to attempt an evaluation of the available forms of support for Polish families with mentally ill children, both with medical recognition and without it. There is a strong need to launch the 'fast track' in the access to psychological or pre-diagnosis support in the family and school environment. This study should be treated as a contribution to the discussion about the need for a coordinated and widely accessible support system for parents and caregivers of Polish children and adolescents.

Mental health of children and adolescents
Psychiatrists distinguish four main areas of mental disorders of children and adolescents: (1) socially maladjusted, destructive and aggressive behaviours (externalising disorders); (2) anxiety disorders, mood disorders (internalisating disorders); (3) mental problems and disorders related to physical illness and/or disability; (4) overall developmental disorders (e.g., the spectrum of autistic disorders). According to many sources up to 20%-30% of children and young people suffer from mental disorders and the problem is growing.
The most common problems of children's mental health are: low self-esteem, lowered mood and resignation thoughts. According to the HBSC (Health Behaviour in School-Aged Children) 35% of Polish adolescents experience everyday tiredness (Mazur, 2018). More and more young people complain about nervousness (36%), irritability (30%), difficulty in falling asleep (24%) and despondency (22%).
About 9%-10% of the population of Polish children and adolescents require professional treatment (Janak-Kozik, 2017). In 2015, over 143,000 people up to age 18 benefited from specialist care and 61% of them were boys. The most common diagnoses were developmental disorders -62% (including disorders of speech and language development, disturbances in the development of school skills, impaired development of motor functions, overall developmental disorders, including autism and Asperger's syndrome), hyperkinetic disorders like ADHD, behaviour disorders); neurotic disorders -14%, mood disorders -3.9% and disorders caused by the use of psychoactive substances -3.3%. In 2015, nearly 200 children were hospitalised due to mood disorders, including depression, and 46 of them were below 14 years old (Szredzińska, 2017).
Not only hospitalisation statistics speak about this increasing threat to children and adolescents. Children look for help on their own and they call helplines. It has to be emphasised that every conversation between an adult consultant and a child means that there is no direct possibility of solving the problem in the family a given child belongs to. Behind every telephone there is a child who for some reason cannot ask for help from adults in its closest environment. Among advantages of online contact perceived by a child we can distinguish reducing the sense of shame or embarrassment (when telling and describing own problem to a stranger), a stronger sense of anonymity, an ability to send messages without limit of time and place. This form of contact allows children to express their own thoughts and feelings, to share problems without exposing themselves to being evaluated and to get a sufficient level of acceptance. The lack of support from adults and strategies in hiding problems (children often PARENTIFY their parents and want to protect them), cause children to declare a sense of loneliness and emotional neglecting. They feel left alone with their worries, devoid of attention and adult care.
The statistics of conversations with consultants of a helpline in 2014 show that the most frequently reported problem areas were peer relations, then sexuality, violence and abuse. From the international project Helping Children at Risk (Polish report: Online help to children in difficult life situations. The specificity of problems reported by children) (Żurkowska, 2015), we learn that the highest percentage of online messages sent by children and young people to the address www.116111. pl regarded areas such as: mental and psychosocial health (35%), peer relations (23%) and family life (N = 4,990 messages). The possibility of sending text messages online (max 3,000 characters) was launched as an alternative form of contact in a situation when the number of consultants in the helpline was insufficient. The most common problems in the area 'mental and psychosocial health' are presented in Figure 1. The most common motive behind the contact is the need to discuss a problem with a professional (19% of messages) and self-mutilation (15%) followed by suicidal thoughts (14% of messages) (Żurkowska, 2015). Socio-medical research conducted by the author describes children's mental health even more accurately. Research carried out in 2017 among the 1,138 students aged 14-18 showed that only 27% of them had coped well with everyday difficult situations ( Figure 2). Nearly half of the students (47%) feel that they cannot cope with stress or feel overwhelmed by everyday problems (31%). Many children experience somatic and mental symptoms of stress (Figures 3 and 4). Almost 70% of them register symptoms such as fast heart rate, shaking hands (56%), sweating (53%). In the area of mental experiences, the children report anxiety (68%), mood changes (39%), distraction and forgetfulness (38%). One third of the children declare low self-esteem and a feeling that something bad will happen (36% each).  The role of the family in protecting children's mental health The family can become a source of emotional problems for children. At the same time, it is the most important environment in which support can be provided quickly, directly and effectively. Parental support, defined as the amount of acceptance and warmth shown to children plays a decisive role in promoting healthy adjustment to stressful situations (Bean, Barber & Crane 2006;Grzegorzewska, 2016). The literature indicates parents' support as an important factor reducing the risk of disorders (Krajcer, 2014) and increasing the psychological immunity of teenagers (Grzegorzewska, 2011).
The family gets the first impact of its child's mental crisis. In heathy relationships, parents quickly notice a problem and have the resources necessary to solve the child's problem (or know where to get them). But even in normally functioning families the symptoms of a mental crisis might be unnoticed. Researchers observe that the number of young people positively assessing the level of support from parents is alarmingly decreasing.
According to data from recent HBSC surveys, the low level of perceived parental support refered to 38.3% of young respondents (and only 23% of them declared a low level of peer support). Between 2014-2018, the average level of support from the family remained at a similar level, but the percentage of negative assessments increased.
Older adolescents, both boys and girls, declare a diminishing level of the perceived parental support: the difference between 11-year-olds and 15-year-olds are nearly 29 percentage points. Comparing the current results with the results of previous HBSC studies (Mazur, 2015), the severity of adverse changes in the perception of parental support is evident with the increasing age. In the group of 13-and 15-year-olds significant differences in the assessment of the level of support from parents between boys and girls were found, to the disadvantage of girls (Zawadzka & Korzycka, 2018).
The research results of the Wroclaw youth indicate a great sense of loneliness and separation from help among the tested group. While in private, out-of-school situations, parents are supportive for 70% of children, at school-related situations this help is available only for 40% of young people. As shown in Figure 5, peers are the strongest support group at school, not adults. The results show that up to 30% of children cannot benefit from the help of parents in the so-called private life, and in relation to school problems, the percentage of children increases to 60%.  Seeking the reasons for these conditions, the good communication in the family must be emphasised. According to data from the recent HBSC studies, 84.5% of the surveyed students evaluate their conversations with their mothers as easy or very easy, while 15.5% find them difficult or very difficult. At the same time, 71% of the surveyed students evaluate their conversations with their father as easy or very easy, and 29% consider them very difficult. The ease of discussing problems important for children decreases with age (Ostręga, 2018). Families with chronically ill children have specific problems. The researchers underline that negative family interactions, particularly critical parenting attitudes (i.e., criticism, nagging, negativity), might be associated with worse adherence and metabolic control as well as lower selfefficacy and more pronounced depressive symptoms in diabetic preadolescents and adolescents (Armstrong, Mackey & Streisand, 2011;Duke, Geffken, Lewin, Williams, Storch & Silverstein, 2008).
In everyday situations, there are several factors affecting the velocity and adequacy of helping the child in health crisis. Involvement in professional responsibilities, extending time spent away from home, a need to meet financial obligations and stress can significantly reduce the quality of communication in parent-child relationships.
In the face of a child's mental crisis, parents may unconsciously avoid defining the situation and not notice the symptoms or underestimate them. The reasons behind a situation in which a child does not receive support from parents vary. They can be generally divided into barriers that hinder or delay triggering processes supporting children in a crisis. Barriers in providing support may occur both on the supporting side (parents, caregivers) and on the supported side (a child). For example, on the one hand, parents cannot read the signals expressed by a child, but children sometimes have no competence to express them. Parents, in turn, often forget that children have less competence and less experience in expressing emotions, especially negative ones. Young people are worried that they will be misunderstood and misjudged. Some parents may also block expressing negative emotions (do not cry, do not get hysterical). A summary of these factors is provided in Table 1.
In addition to low communication skills of children and the lack of proper parent reaction, parentification becomes the second important phenomenon. A child hides his/her problem, pretends to be a brave 'little boy' or a 'brave girl' and does not want to worry busy parents, striving for the family welfare. Parents often act similarly: they do not tell children about their troubles and think that they will protect their children. In this way, the child does not learn to talk about his/her anxieties and failures.
There are several reasons behind the displacing of the child's problem. Lucyna Kicińska from the Empowering Children Foundation underlines that the first reason for diminishing the importance of the situation is being unable to accept that their child is suffering (because it is really hard to accept it). They also feel guilty that they did not notice the problem earlier and they feel ashamed when they realise that they have made parental mistakes. Additionally, there is a strong cultural pressure on the family to be ideal and that internal problems should be hidden (Dutkiewicz, 2018). The most frequent parental mistakes might include: 1. The parent plays a role of a specialist, mother or father 'knows better' (I tell you son, your problem is not so hard…). 2. They play roles of 'superheroes' -rescuers, arbitrators, trouble-solvers. And they say what their child has to do. So they give 'golden advice' (You have to be more assertive, Don't talk to him). This advice is strongly unfamiliar and extraneous, does not fit to the child's small world. Parents forget that children are not so socially experienced and they have much fewer possibilities of reaction. Or they are simply afraid of new situations or changes. 3. Parents try to control their child's behaviour when a problem is already visible (to limit drug taking) but do not know how to eliminate the cause of this harmful activity. 4. Parents have difficulties in asking for professional help in the mental health area.

Table 1. The list of factors (behaviours) hindering the proper intervention leading to solving the problems from a child's and parents' perspective
Child with a problem -the child's perspective Child with a problem -the parents' perspective • Children do not always know how to communicate the problem in a 'readible' way (e.g., they use the Morse alphabet to tap 'help' during a family supper) • Parents cannot see a problem, because they cannot 'read' the signals and communications given by their child • Children hide bad feelings (even for 3 years), they wait and hope that their mother/father will guess and name the problem • When the problem becomes more visible, parents often displace it, try not to see it for several reasons • They 'parentificate' adults, want to protect busy and overtired parents • Parents do not talk about their problems to protect the child. As a consequence, the child does not learn how to communicate about its worries or failures.
• Every child who is calling a helpline feels that he/she cannot talk to their parents about its problem • Parents react in an unappropriate way (they judge the child's behaviour) • Parents have difficulties in asking for professional help in the mental health area • Parents are overloaded by everyday duties/ and or have their own health problems (like depression) Source: own elaboration.
The most important parents' deficiency is their parental incompetence in recognising and understanding the warning signs of mental illnesses of their children and how they could help their child to cope. There is also another need in this area. Even if they know the 'red flags' , it can be difficult for them to distinguish signs of a problem from the normal childhood behaviour. And children often lack the vocabulary or developmental ability to explain their concerns. Concerns about the stigma associated with a mental illness and pharmacology might also prevent a parent from seeking professional care for a child who has a suspected mental illness. Public health professionals should take into account that probably a lack of stable family care is partially responsible for difficulties in controlling harmful activities, like self-mutilation or using new psychoactive substances (Uzar, Guśtak, Matusiak & Borys, 2018).
Evaluation of the support for parents in the protection of the mental health of children Support and promotion of the youth's mental health should be a task primarily for parents (the family) but also for school workers and medical staff. As it was mentioned, parents meet many cognitive, emotional and cultural obstacles in taking proper action. The mental health care system is based on stationary care wards (only 40 in Poland, located irregularly and accidentally). The occupancy rate is 165% and it means that the system is unable to provide any effective prevention and help to those in health crisis. There are only 419 psychiatrists specialised in child care (Maślankiewicz & Bójko, 2019). Important issues of child psychiatry include the outflow of specialist staff, which may result in the closure of new wards in situations when there are no places in hospitals. Unfortunately, the critical situation in psychiatry in Poland and a lack of many important services has a crucial impact on the medical and economic effectiveness of treatment. The limited access to medical services (lines, a lack of beds), pressure on hospital treatment (sometimes it is the only option for a family) and a lack of environmental forms of support lead to discontinuous and partial care.
Parents may try to apply for help to one of the pedagogical and psychological counselling centres (1,400 in the whole country), but usually they must wait several months. If they do not or cannot wait, they might pay for private counselling in psychotherapy practices and centres (about 3,000). Theoretically, there should be a psychologist in every school in Poland, available for every need of children, parents and teachers. In practice, schools cannot provide early prevention because 40% of them do not hire psychologists. School support teams (psychologist, educator) established in school facilities in accordance with the ordinance of the Minister of National Education often do not have the knowledge about dealing with children with mental disorders. They also cannot use the support of experts who could help to involve students after hospitalisation in the school's life.
There is no successfully implemented mental health programme in Poland, neither for adults nor for children. Although we have many different institutions involved in mental health protection tasks, there is a lack of proper coordination and cooperation enabling adequate assistance for necessitous children and their families.
Patients and their relatives have no support in the institutional environment of the family, either. There is no 'quick reaction path' , allowing experts to observe and define the core of the problem and to indicate possible causes. That is why many children go to hospital, because the cause of bad self-esteem cannot be determined after 1-2 years of a symptom duration. This quick path should start with a conversation between the concerned parent and a specialist (psychologist, environmental therapist) and lead to the decision what kind of support is needed for a child and their caregivers (separately). The separated examples of the local system of community psychiatric treatment (an alternative to the inpatient and outpatient care) for children and adolescents show that the proper way to support families are deinstitutionalisation and quick access to open dialogue (Surma-Kuś, Pilawski, Siwiec & Janas-Kozik, 2018). The strengths of the programme are: accessibility and persistence of medical care, home visits, mobility of medical staff (psychiatrists, nurses, psychologists), focusing on social functioning of the patient (in school, at home).
One of the best researched and most effective interventions for reducing child mental health problems are parental programmes based on social learning and cognitive behaviour theories (Gardner, Hutchings, Bywater & Whitaker, 2010). In Poland such programmes are rare and dispersed. There are no widely accessible workshops for parents expecting a child and parents of young children about how to recognise and cope with various symptoms and disorders in everyday life. The main condition of success in such programmes is a high level of parental engagement and mobilisation. It can be noticed that the problem lies not only in parental reluctance to participate (parents sometimes think that when joining the programme they automatically admit to their own failure in parental duties). The level of attendance and activity of mothers and (especially) fathers are highly variable but they are an important factor in implementing new types of behaviour. Researchers and practitioners should investigate and improve models of cooperation with parents taking into account the role of the 'parenting team' and the whole family. Piotrowska et al. presented an interesting theoretical model of empowering parental engagement and perseverance in changing their own and/or child's behaviour (Piotrowska, Tully, Lenroot, Kimonis, Hawes, Moul, Frick, Anderson & Dadds, 2017).
Of great importance are all preventive measures directed at parents, enriching parents' knowledge about typical behaviours of children at different ages, such as the 'two-year rebellion' or the need for an adolescent rage. This allows parents to respond adequately to the child's behaviour and increases the chances of catching alarming symptoms. Free of charge workshops and preventive programmes are rarely conducted by NGOs, like the Children Empowerment Foundation. The offered forms of support consist of: mutual-support groups for parents (families) or online lectures and workshops How to build the leadership in the family. Under the supervision of specialists, parents acquire competences that raise their educational abilities and contribute to strengthening positive family interactions. The opportunity to talk with other parents helps to stabilise emotions and minimise the probability of inappropriate reactions that may lead to underestimating the symptoms of a child's mental crisis. The essence of mental health counselling lies in organising psychoeducational workshops, as well as individual consultations with specialists: a psychiatrist, family therapist, addiction therapist or psychologist.
Participation in parenting workshops dedicated to a specific disorder of a child (e.g., ADHD) or improving competences in diagnosing depression symptoms may lead to an increasing sense of resourcefulness and reduce feelings of anxiety and insomnia. Indirectly, the professional and non-professional (mutual) support allow for reducing the severity of parental stress (Pisula, Bryńska, Wójtowicz, Srebrnicki & Wolańczyk, 2019). Participation in parenting workshops increases the parental influence on children's behaviour. In the case of families with children with coupled dysfunctions, the Family-Centred Empowerment Model is becoming more and more popular. According to the modern concept of medical care, the paradigm of assisting a child with disability, focused on specialists, gradually gives way to a new approach: a model for supporting a child based on the family (Twardowski, 2014).
Social prevention and activities aimed at supporting families should focus primarily on activities that will increase knowledge about children's needs, but eventually they should promote positive parent-child interactions and ways of maintaining family ties. An important element here is also the strengthening of parental competences and the ability to search for and develop beneficial relationships in the immediate and wider environment of the family. The condition for this is that parents have knowledge about how to deal with emotions and stress (their own and the child's) and the skills of effective communication and methods of strengthening relationships. One of the strongest competences is an ability to build social networks, giving relevant support.
Helplines are the only widely known and popular among adolescents forms of professional support. Poland has the free of charge nationwide Helpline for Children and Adolescents (116 111) and the Helpline for Parents and Teachers for Children's Security (800 100 100). The helplines are offered also by the Supporting Centre for Persons in Mental Crisis -800 70 2222 (free of charge, available 24/7) or the Crisis Helpline for Adults (116 123 -free of charge available every day from 2.00 to 10.00 p.m.). The Spokesman for Children's Rights has also his own number (800 12 12 12) as well as the Police (800 12 02 26). Parents can find help calling the Anti-depressant Helpline and online forum (operates every Wednesday and Thursday 5.00-7.00 pm; (22 594 91 00). Local helplines operate in many cities. Parents may always call, regardless of the case, Emergency number 112.
A very popular way to seek support are online conversations, forums and parental blogs. On websites in Poland we can find stories of teenagers who struggle with depression (www.porcelanoweaniolki.pl) or advice on how to find professional and non-professional help (pokonackryzys.pl, liniawsparcia.pl, pogotowieduchowe.pl).
The public offer of help for families in which children undergo a psychological crisis (or other mental health problems) lacks financial and human resources. Only long-term financial transfers from the state budget allocated in a coordinated system can transform today's scattered activities. Some municipalities already see the scale of the problem and dedicate additional funds to current needs in terms of supporting parents (Środki…, 2017). However, these are rare cases.

Conclusion
Mental health problems are treatable nowadays, but for best clinical results one needs an early identification and intervention in the patient's closest environment. The family is the first group which meets an emotional crisis, behavioural disorders and other mental dysfunctions in children. Parents (caregivers) should have the necessary competences to catch the symptoms of a problem at an early stage, but also to properly assess their validity. Estimating the severity of symptoms does not have to ground on a wide medical knowledge, but on access to such knowledge (online or a conversation with a medical professional) and self-efficacy. Mental health counselling is the best way to discuss doubts and questions important for parents concerning children's mental problems. Poland lacks a professional (institutional) support system, and non-institutional activities are insufficient. Parental preventive programmes are not accessible. The level of support for families in protecting the mental health of children still requires coordinated and swift actions.