## Study Notes: Building Our Solutions and Connections (BOSC) Intervention for Caregivers of Children with Mental Health Problems This study investigated the feasibility, acceptability, and effectiveness of the Building Our Solutions and Connections (BOSC) intervention for caregivers of children with mental health issues. The intervention aimed to reduce caregiver burden and depressive symptoms. ### I. The Problem: Caregiver Burden and Depression Caregivers of children with mental health problems often experience significant emotional and practical challenges. * **Symptoms:** Caregivers may experience symptoms related to their child's mental health struggles, including aggressive behaviors, suicidal threats, the child's distress, and deterioration in various settings (family, school, community, legal). * **Emotional Toll:** The experience frequently leads to profound feelings of loss, constant fear, and worry about the child's future. * **Lack of Intervention:** Surprisingly, few interventions specifically target caregiver burden and depression. Understanding the significant burden placed on caregivers is crucial for developing effective support systems. ### II. Intervention Strategies: BOSC The BOSC intervention is a cognitive-behavioral problem-solving intervention (PSI) adapted from the IMPACT Program. #### A. Conceptual Foundation: Transactional Theory of Stress and Coping The BOSC intervention is grounded in Lazarus and Folkman's transactional theory, which posits that stress arises when demands exceed available coping resources. * **Stress as Transaction:** Stress results from an individual's appraisal of demands exceeding their resources. (See Figure 1 in the original text for a visual representation of this model). * **Personal Control:** D'Zurilla's theory highlights the link between personal control and problem-solving, emphasizing the belief in one's ability to manage problems. #### B. Intervention Components * **Cognitive-Behavioral Problem-Solving (PSI):** Caregivers learn a seven-step problem-solving process: 1. Evaluate previous week's outcomes. 2. Select and define a problem. 3. Establish realistic goals. 4. Generate multiple solutions (brainstorming). 5. Implement decision-making guidelines (pros and cons). 6. Evaluate and choose solutions. 7. Implement chosen solutions. * **Emotion-Focused Strategies:** Techniques like cognitive reframing and scheduling pleasurable activities are incorporated to manage emotional impact. * **Proximal vs. Distal Outcomes:** The intervention aims for proximal outcomes (perceived personal control, problem-solving skills) leading to distal outcomes (reduced burden, fewer depressive symptoms). A caregiver might use the PSI steps to address a problem like their child's refusal to attend school. They would define the problem, brainstorm solutions (e.g., talking to the school counselor, creating a reward system), choose a solution, and implement it, evaluating its effectiveness along the way. ### III. Study Design and Methods #### A. Research Design * **Experimental Design:** A randomized controlled trial (RCT) comparing the BOSC intervention group to a wait-list control (WLC) group. * **Sample Size:** Initially aimed for 66 participants (33 per group), accounting for a projected 30% attrition rate. * **Randomization:** Participants were randomly assigned to groups, stratified by child behavior problems, caregiver depression, and burden. Failing to account for attrition rates in study design can lead to underpowered studies and unreliable results. #### B. Participant Inclusion/Exclusion Criteria * **Inclusion:** Primary caregivers of children (11-16 years) receiving mental health services, English-speaking, living with the child, biological/adoptive/foster parent/relative/guardian, scoring ≥10 on the PHQ-9 depression scale and/or ≥2.0 on the PES burden scale, and at least 21 years old. * **Exclusion:** History of schizophrenia, bipolar disorder, substance abuse, or psychosis. #### C. Data Collection Data were collected at four time points: baseline, 1 week post-intervention, 3 months post-intervention, and 6 months post-intervention. #### D. Intervention Delivery * **Training:** A 1-hour face-to-face training session followed by up to eight 30-minute weekly telephone interventions. * **Treatment Fidelity:** Interveners were trained using a manual, audio-taped sessions were reviewed, and supervision was provided. #### E. Instruments * **Demographics:** Collected information on child and caregiver characteristics. * **Child Behavior Problems:** Measured using the Child Behavior Checklist (CBCL). * **Proximal Outcomes:** * **Perceived Personal Control:** Measured using the Pearlin Mastery Scale (PMS). * **Problem-Solving Attitudes and Skills:** Measured using the Social Problem Solving Inventory-Revised, Long Version (SPSI-R:L). * **Distal Outcomes:** * **Depressive Symptoms:** Measured using the Beck Depression Inventory II (BDI-II). * **Burden:** Measured using the Parent Experiences Scale (PES). * **Acceptability:** Measured using the Client Satisfaction Questionnaire (CSQ-9). The use of multiple validated instruments strengthens the reliability and validity of the study's findings. #### F. Statistical Methods * **Analysis of Covariance (ANCOVA):** Used to compare group differences on outcome variables, adjusting for baseline scores and covariates. * **Effect Sizes:** Partial η² was used to estimate effect sizes. * **Post-Hoc Analyses:** Further analyses were conducted to explore potential moderators (depression, burden) and the impact of antidepressant medication. ### IV. Results #### A. Feasibility and Acceptability * **Feasibility:** The study met its recruitment goals, suggesting the intervention's appeal. However, only 60% of BOSC participants completed at least seven of nine sessions. * **Acceptability:** Satisfaction ratings were generally high (mean 3.5/4), but some participants expressed a preference for more face-to-face sessions. #### B. Intervention Effects * **Primary Analyses:** No significant differences were found between BOSC and WLC groups at any time point in the primary analyses. * **Combined Group Analysis:** When both groups' data were combined, significant reductions in depression and burden were observed immediately post-intervention and at 3-month follow-up. * **Long-Term Effects:** The positive effect on burden was maintained at 6 months, but depression returned to baseline levels. * **Post-Hoc Analyses:** Subgroup analyses revealed larger effect sizes for caregivers with high depression who completed most sessions, particularly for burden. The lack of significant differences in the primary analyses highlights the importance of considering subgroup analyses to identify those who benefit most from the intervention. ### V. Discussion and Conclusion The BOSC intervention showed promise in reducing caregiver burden, particularly for caregivers with high depression who adhered to the intervention. However, the lack of sustained improvement in depression suggests the need for modifications, such as booster sessions. The study's findings highlight the importance of addressing caregiver burden and depression to improve the well-being of families affected by children's mental health problems. Future research should explore intervention modifications, potential moderators, and the long-term impact of the intervention.