Dialogical Family Guidance (dfg)—Development and implementation of an intervention for families with a child with neurodevelopmental disorders

Abstract Aim To describe the development and implementation of a Dialogical Family Guidance (DFG) intervention, aimed at families with a child with neurodevelopmental disorders (NDD). Design The DFG components are presented and the content of a DFG training course. Professionals' experiences after the DFG training were evaluated. Methods Dialogical Family Guidance development phases and implementation process are examined. The Revised Standards for Quality Improvement Reporting Excellence checklist (SQUIRE 2.0) was used to provide a framework for reporting new knowledge. Results The DFG training course seemed to increase possibilities of a more independent role as a nurse to deliver the DFG family intervention. The project showed that the use of dialogue can be difficult for some professionals. Analysis of the questionnaire completed after DFG training reported a high level of satisfaction. DFG training offered a new approach to deliver knowledge and understanding to families using dialogue, including tailored psychoeducation and emotional and practical guidance.

. This article describes the development and implementation process of a family intervention called Dialogical Family Guidance (DFG) aimed at families with a child with NDD (neurodevelopmental disorders). The DFG-educational elements are also presented.
Neurodevelopmental disorders is a general appellation to describe neurological and psychiatric disorders with an early onset in childhood. Neurodevelopmental disorders includes learning and language disorders, motor coordination disorders, intellectual disabilities, autism spectrum disorders (ASD), attention-deficit/ hyperactivity disorder (ADHD), tic disorders and oppositional defiant disorder (ODD). Common comorbidities are sleeping disorders, feeding problems and various sensory processing problems. A change in symptom/developmental profile may occur during the childhood period which is further emphasized in the concept of ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) created by professor Gillberg from University of Gothenburg. The ESSENCE concept covers NDD, and problems/symptoms not meeting the criteria for a certain NDD diagnosis (Gillberg, 2010;Thapar, Cooper, & Rutter, 2017). A family intervention model designed with a focus on the individual family's needs and questions has been advocated for this particular group (Cavonius-Rintahaka, Aho, Voutilainen, Billstedt, & Gillberg, 2019).

| Background
Parenting stress, family dynamics and family function surrounding the child´s disorder should be considered when developing interventions for families with a child with NDD (Ho, Chien, & Wang, 2011;Wiener, Biondic, Grimbos, & Herbert, 2016). Subsequently, there is also a need to translate the heightened stress, illness and psychiatric problems occurring in parents of children with NDD into effective interventions (Dykens, 2015). Dykens (2015) points out that both parents and the siblings in the family need accurate and targeted guidance and information. It is known, for example, that ADHD is associated with problematic family functioning, including greater stress in the family, higher rates of parental psychopathology and conflicted parent-child relationships, and this appears to exacerbate in children with comorbid oppositional and conduct disorders (Deault, 2010). Also, autism symptom severity is significantly correlated with maternal stress (Duarte, Bordin, Yazigi, & Mooney, 2005).
When providing support to parents with children with NDD, the focus needs to be on the entire family and not only on the child with the diagnosis. However, it is also noticed that there are differences between mother's and father's ways of coping with their child's diagnosis and stressful life events. Parents have different personalities and parenthood behaviours. Studies highlight the need to translate parents' heightened stress and siblings' needs, to give accurate and targeted guidance and offer effective interventions to strengthen the well-being of the whole family (Duarte et al., 2005;Falk, Norris, & Quinn, 2014).
Open dialogue was originally developed as a method for healthcare teams to help adult psychosis patients in Finland but has since been implemented in different countries and modified to fit different healthcare organizational needs. Consequently, open dialogue no longer seems to be a therapeutic method but rather the ability to see the polyphonic nature of the client's reality. The base from which to offer professional help is realized by listening carefully to what the client and family members have to say (Anderson, 2002;Buus et al., 2017;Rober, 2010;Seikkula, Arnkil, & Eriksson, 2003).
By using the dialogue approach and supporting dialogue in conversation, nurses and other professionals can help families with a child with NDD get through distressing life events and demands.
Especially, giving grass-root attention to the voices of individuals and families, speaking from experience is important over the treatment (Post, Pomeroy, Keirns, Cover, & Dorn, 2017). As a further consideration, NDD symptoms and diagnoses are strongly heritable, and subsequently, more than one family member can have special needs or special difficulties that fall under the NDD symptom umbrella (Lichtenstein, Carlstrom, Rastam, Gillberg, & Anckarsater, 2010;Thapar & Cooper, 2016).
There is no doubt that providing education increases knowledge and positive attitudes and behaviours towards individuals with NDD. To accomplish dialogue, professionals themselves need to adopt a positive and cooperative attitude. This attitude includes aspects such as understanding, empathy, flexibility, a high motivation to cooperate with families and a willingness to help them (Anderson, 2002;Buus et al., 2017;Seikkula et al., 2003). It is known, for example, that primary caregivers of adolescents with ADHD experience better quality of life, family functioning and parental coping after Therapeutic Conversation Intervention, and therefore, this intervention has been recommended for nurses in hospitals and at healthcare centres, where ADHD services are provided (Gisladottir & Svavarsdottir, 2017). Negative attitudes and a lack of time can be a threat to parents' confidence. Thus, the attitude of the parents and their willingness to cooperate is also an important factor when trying to achieve optimal results. Cavonius-Rintahaka et al. (2019) conducted a pilot study about families' health, functionality, hopes and expectations and confirmed that families with a child with NDD seemed not to get the help they expected from professionals. Notably, parents, both hoped and expected professionals to listen, have dialogue and give attention to the entire family. Therefore, the Dialogical Family Guidance intervention is an important step forward in trying to meet parental and family needs.

| ME THODS
The aim of this paper is to describe the development and the implementation process of the Dialogical Family Guidance (DFG) family intervention. Important components of the intervention and the implementation process into the clinical setting are presented, including the DFG-educational process developed for professionals. A post-training evaluation was carried out for professionals who had taken part in DFG training to collect data about their satisfaction concerning the training they had received.
A tailored questionnaire with 10 questions about DFG training (Likert scale 1-7) was completed after the training by 26 professionals. One open-ended question was included. The quantitative data were analysed by using the SPSS statistical programme, and the results of the open-ended question are presented as a summary. The Revised Standards for Quality Improvement Reporting Excellence checklist (SQUIRE 2.0) has been used to provide framework for reporting new knowledge about how to improve health care (Ogrinc et al., 2015) and has also been employed in this study (Appendix S1).

| Literature review
A review of the literature presents psychoeducation as a commonly used and valuable intervention for families with a child with NDD (Nussey, Pistrang, & Murphy, 2013). It has been defined as a systematic and didactic approach, adequate for informing patients, relatives, school staff, etc., about the condition and for implementing educational programmes related to a child's disorder. According to the literature, effective psychoeducation is carried out by a sensitive and sympathetic therapist, lasting approximately 60-90 min and including 4-6 sessions (Bauml, Frobose, Kraemer, Rentrop, & Pitschel-Walz, 2006). Studies of psychoeducation show that children and adults with NDD, and families and teachers, benefit from this TA B L E 1 Summary of seven interventions aimed towards families with a child with NDD

Author
Intervention Content Potvin et al., 2018. USA Coaching in context (CinC) Family-driven support for children with autism and their families combining coaching and context therapy. Professionals coach the whole family, and the intervention is said to be family-driven. However, it is actually a parent-mediated structured process. Parents deliver the intervention in practice to their child. This involves families in goal setting, designing, implementing and evaluating during the process. The coach gets support from an inter-professional team, and this is called the "key" in this process. This is a descriptive paper, and CinC has not been tested. Use of dialogue Empirical study about the role of public health nurses (PHN) and families with a child with ADHD. The aim of the study was to explore the PHN role in relation to families with a child with ADHD. The paper points out the importance of building a good relationship with parents using dialogue and, continuity. Supervising parents also requires dialogue, and the PHN's support for parents and the entire family is important.
Bauer & Webster-Stratton, 2006. USA Importance of prevention by, for example parenting programmes This paper reviews selected parenting programmes for children aged 2-8 years to inform the options available to families with children with behaviour problems. Parent training programmes are an effective option to promote positive parenting. It is essential to think not only of how to screen and treat, but also of how to prevent behavioural problems.  Table 1 for examples). However, it seems that any dialogue or dialogical elements are often overlooked or missing because dialogue is only randomly mentioned.
It should be noticed that although many interventions seem to offer a family intervention, they often only target the parents in the family and are thus parent-mediated. This means that it is much easier to find "parenting programmes" than "family interventions" where siblings are in focus alongside the parents. However, earlier studies highlight similar important elements that are included in

F I G U R E 1 Content of the DFG areas
The medical and nursing knowledge behind DFG is a combination of understanding the complexity of NDD (Thapar et al., 2017) and ESSENCE (Gillberg, 2010) and then having the competence to transform it into practical guidance for families to help them in their daily life. Traditional background elements of family therapy such as Open dialogue (Seikkula & Trimble, 2005), reflection (Weingarten, 2016) and systems therapy (Haefner, 2014) are influencing DFG background theories. But especially, the dialogic approach is key to this family-targeted intervention.

| Development of the DFG family intervention
Dialogical Family Guidance is designed to help all family members to receive knowledge and gain an understanding of NDD/ESSENCE. As mentioned earlier parents with children with NDD can have symptoms similar to their children due to the high degree of heritability (Thapar et al., 2017). Attention-deficit/hyperactivity disorder symptoms in adults may present as inner restlessness, impatience and difficulties to sit still in meetings (Zalsman & Shilton, 2016). Poor time management skills can also appear, and these features need to be noticed, because the parent's own symptoms along with, for example impulsivity and attention disorders, can cause difficulties for parents to complete longer intervention processes. Low self-concept might decrease parental expectations of being able to deal with emotional situations, and an experienced failure of emotion regulation might stabilize negative thoughts about oneself (Hirsch, Chavanon, Riechmann, & Christiansen, 2018). As mentioned before, psychoeducational interventions usually last 60-90 min including 4-6 sessions (Bauml et al., 2006). Accordingly, the DFG intervention includes six different sessions lasting 90 min per session. Given the issues mentioned above, any longer intervention process could potentially minimize the parents' own motivation and commitment, so establishing a time schedule for the sessions provides a sense of security for the family members.

| Description of the DFG sessions and its three main components
The general approach in DFG is dialogical with an emphasis on collaboration between DFG therapists and family members to find solutions and make family resources visible. Using dialogue, DFG therapists gain knowledge about, for example the family system, parenthood, family crises and siblings´ reactions within the family.
Open dialogue invites family members into a mutual learning process (Rober, 2010;Seikkula & Trimble, 2005). DFG offers a collaborative working process for all family members over six meetings within 3 months. noting is that this may be the first opportunity for parents to talk openly about these matters (Table 2).

| The three main components in DFG
Practical/concrete guidance includes tailored guidance con- Mothers and fathers operate and function from their own personal starting point, and therefore, the guidance is also personalized. A different approach is needed if there are children/siblings present (Table 2).
Emotional guidance includes DFG therapists being reflective and listening to family members' unique life situations without prejudice or pre-held attitudes. One goal is to increase families' own activity and functionality, by making the family members' own resources visible. In this way, the family's overall well-being can be increased.
Emotional support is provided by listening and verbally supporting family members as they discuss their concerns and helping them to develop personal skills and abilities (Table 2).

| Family sessions 1-6
Session 1 is dedicated to practical arrangements termed as the setting (place, time schedule, planning and frequency of the meetings).  Table 2.
After each session, the DFG therapist makes notes on the DFG checklist about which themes have been discussed and which themes still need attention. This assures that all three of the DFG guidance components and themes have been handled during the DFG sessions. This checklist policy provides a quality factor for the DFG family intervention and helps providers to take commonly important themes into discussion, while paying attention to the individuality of the family at the same time.

| Training for professionals to become a DFG therapist
The DFG training course includes theory-and experience-based knowledge. The topics of DFG training are presented in Table 3.
The educational goals for professionals are as follows: 1. That the principles and substance of DFG are well understood.
2. That participants increase their knowledge or confirm their own existing knowledge about family dynamics and parenthood in families with children with NDD, including emotional aspects.

That participants can proceed and perform DFG independently
(or with another DFG therapist).

| DFG implementation
Readiness for implementation to a clinical setting requires a lot of communication between actors on different administration levels.
The personnel involved are in the best cases motivated to work alongside each other and cooperate during the implementation phase This was important as nurses and other professionals proceeded with their training and prepared for independent work as DFG therapists.
In some case (mainly involving nurses), the professional's job description needed modification to assure their possibility to proceed with the DFG intervention after DFG training as a part of their clinical work. The professionals own motivation and willingness to attend DFG training were seen as an important selection criteria.
Approval from the hospital ethical board was applied for, so as to be able to test the effectiveness of DFG in the future from the families' point of view. Acceptance from the hospital ethical committee of psychiatry (106/13/03/03/2012) and research approval from the hospital board was received from 2012-2019.
A manual has been created to help DFG therapists in their work.
The manual includes six different themes which can be used flexibly during the DFG sessions. The manual gives structure to the DFG process, and using the manual has been felt to be highly beneficial by DFG therapists.  dialogue and whether they would you recommend DFG for families and DFG training to other professionals. The survey data were analysed using the SPSS statistical programme.

| RE SULTS
At this hospital, nurses and social workers completed the education programme between 2016-2019. However, it is mainly nurses, often working in pairs with families during the DFG process. This helps professionals to learn and internalize this new intervention and minimize their own tension. Participating on the DFG training course seemed to increase the possibilities of a more independent role as a nurse being able to deliver the DFG intervention to families.
The education programme offered the possibility to rehearse the dialogue that can be used in practice. The use of dialogue was also an important pedagogical method giving experiences of being listened to during the DFG training process. Comments, questions and the narratives of participants were important dialogical elements that featured in the DFG training. Worth noticing in this project was that using dialogue can be difficult for some professionals. Also, the expectation of taking all of the family members into consideration, instead of focusing only on the child with NDD, can be demanding.
Therefore, one assumption is that not only experience and skills, but also the personality of the professionals involved, affects how DFG is delivered for the family.
The analysis of the questionnaire completed after DFG training reported a high level of satisfaction concerning the training itself and the question "Would you recommend the DFG education to other professionals" was answered "absolutely yes" or "yes" by 96% of respondents. Regarding their perceptions of the usefulness of DFG initiative itself, the question "Would you recommend DFG for families" was answered "absolutely yes" or "yes" by 100% of respondents.

| D ISCUSS I ON
This article describes the development and implementation of a Dialogical Family Guidance intervention, aimed at families with a child with NDD. As previously mentioned, the DFG development and implementation process evolved from clinical experiences involving parents' narratives, and drawing from data from a pilot study (Cavonius-Rintahaka et al., 2019). Forming a functioning family intervention for this target group and implementing it successfully in clinical practice has been a long-term project.

F I G U R E 2 The DFG development and implementation process
Reflecting previous knowledge and literature, there is no doubt that family interventions are needed for families with a child with NDD, especially when a specific demanding behaviour is involved (Dykens, 2015;Post et al., 2017). It is also well known that information about symptoms and diagnoses, as well as tips and advice when operating with these children in daily life are important parts of psychoeducation initiatives (Bauml et al., 2006;Nussey et al., 2013). But this knowledge alone seemed not to be enough. According to families on whom the demands of not only taking care of the child with special needs, but also the siblings and the relationship between parents had an impact, raising children with NDD is challenging for parenthood and over time there are risks to the parents' own mental health in terms of anxiety and depression if they do not receive help (Falk et al., 2014

| Limitations
Relatively, few professionals have taken part in the DFG training course, although many more are on a waiting list for DFG training.
Unfortunately, the DFG training course evaluation received responses only from 26 of the 44 professionals who had taken part, so the lack of depth in data makes it too early to know whether the training course needs modifying, although preliminary experiences and feedback from participants were very good. The DFG implementation process described in this paper relates only to one university hospital, and therefore, the results cannot be generalized. A however, this study is in progress and once complete; findings will be used to modify the DFG if necessary.

| CON CLUS IONS
The

| Relevance to clinical practice
This paper presents the DFG family intervention development and implementation processes, together with the details of the DFG education process and programme components. This information can be useful to nurses working with similar families and clinical surroundings, but the information can be applied by various professionals working in a setting that involve families with a child with NDD.
This paper can offer tips to developers working in different areas to help them develop their own family interventions and implement them in different units. This paper hopefully increases the awareness of the importance of offering these families dialogical interventions that include all family members.

ACK N OWLED G EM ENTS
I want to thank the hospital leaders and other professionals at Helsinki University Hospital for their activity and collaboration to make DFG educations possible as an important part of ordinary work and for their activity to put DFG into practice with families.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data are available on request from the corresponding author.