Abstract
ecently released documents from Australia, the USA and Britain highlight the needs of many families where parents have a psychiatric disorder. 1– 1 However, there is currently a lack of systematic data regarding the number of adults utilizing mental health services who are also parents of dependent children. A recent Australian study noted that many adult mental health services do not (or have only recently begun to) record whether their clients have children. 5
Various surveys and audits in the USA and in Britain suggest that at least 20% and in some cases up to 50% of adults known to mental health services have children. 6 Australian surveys have found that between 29% and 35% of mental health services clients are female parents of dependent children under the age of 18, 7– 9 and in 1995 Cowling et al. estimated from census data and incidence rates that at least 27 000 Australian children were affected by maternal psychotic illness alone. 10 High prevalence rates (of approx. 13%) for major depressive disorder in women in the postnatal period are well documented. 11
IMPACT OF MENTAL ILLNESS UPON PARENTS AND THEIR CHILDREN
The association between parental mental illness and adverse outcomes for offspring has been well established, 12– 21 but not all children of parents with a mental illness will experience difficulties as a result of their parent's health status. 22 Estimates suggest that between one-third and two-thirds of children of parents known to adult mental health services will experience difficulties, dysfunction or disorder, depending on sampling and assessment criteria. 6 A combination of factors including genetic inheritance, psychosocial adversity, the age of child, the nature of the psychiatric disorder, family relationships, and the involvement in the child's life of adults other than the mentally ill parent impact upon the child's risk of psychopathology, and medical and behavioural problems. 15 ,16 23– 28
Although many people fulfil their parenting role exceptionally well despite the presence of significant mental health problems, there are many ways in which parental mental illness can impact on parents' abilities to care for their children. For example, depressed parents who exhibit apathy and listlessness may provide poor emotional support for their child or neglect to tend to their child's physical needs. 29 Distorted perceptions of parents with psychosis may lead to inappropriate care, neglect or abuse. Parents with a personality disorder or substance misuse problems may exhibit poor impulse control, which can lead to violent or inconsistent and unpredictable behaviour. 21 Further, the possible adverse impact of post-partum depression on a young child's cognitive and emotional development is now well recognized. 24
Somewhat surprisingly, the parent's specific diagnosis may have less correlation with the impact on their offspring, than the factors that many parents with psychopathology and their children have in common. 29 Physical separation of the child and parent for lengthy periods, if the parent is hospitalized, may affect attachment. A person's mental illness may result in a reduction in living standards, loss of friends and family or disruption of family and marital relationships, 30 all of which can negatively impact upon a dependent child. 16 Rutter and Quinton noted that because many of the disturbances seen in offspring are not specific to the type of parental psychiatric condition, the significant role played by psychosocial adversities in the family and especially by hostile and anxious parental behaviour should not be underestimated. 31
Falkov has identified several subgroups across a spectrum of need among children living with parents with a psychiatric disorder, ranging from those who appear ‘well’ to those who are vulnerable and in need of support, treatment and, on occasion, protection. 6 He notes that a child may move in any direction along this spectrum of ‘risk’ over their lifetime, and his child fatality study in the UK also highlights an additional small but significant group of children who die as a result of parental mental illness. 32 A report for the New South Wales Child Death Review Team noted that the effects of parental mental illness precipitated death in 11 of 60 (18%) cases of fatal child assault in the 3 1 /2 years prior to July 1999. 33
There are many factors associated with a greater likelihood of parents experiencing difficulty meeting their children's safety needs. 3 ,6 ,34 For example (i) children appear to be most vulnerable when parental mental illness or problematic alcohol and drug use coexist with domestic violence; 21 ,34 (ii) parents with a diagnosis of antisocial personality disorder are more likely to exhibit hostile behaviour towards their children than parents with other disorders; 3 (iii) parental self-harm has been shown to have important associations with child maltreatment; 35 ,36 and (iv) psychotic illnesses have been noted to afflict a substantial proportion of parents who kill their children. 32 ,37
A child's vulnerability may also depend upon their age and whether the parent's mental illness coincides with important stages in the child's life. 38 For example, parental depression will have a greater impact on the attachment dynamic if it occurs in the first year of life rather than later, and older children tend to be better equipped to cope with parental mental illness. 6
The stigmatization of people with mental illnesses and its negative consequences can also affect all family members. 39 In addition, the care burden on children of parents with a mental illness (especially in sole-parent situations) may greatly affect their participation in education and social life. 40 It is noteworthy that many children and young people are not well informed (if at all) about their parent's illness and prognosis, nor are they usually given opportunities to have their questions answered. This may lead to unnecessary feelings of fear, confusion and guilt. 41
Parenting is significantly influenced by culture and experience, as are one's responses to the mental illness of a family member. Some factors that may add to the complexity of working with families from diverse cultures include the tendency for children to assume the responsibilities of the parent if the family is geographically and culturally isolated, a reliance on children to interpret information and negotiate service systems for parents with poor English language skills, and ineffectual or inappropriate discipline of children in the Australian context. There may also be particular challenges for survivors of trauma and torture, or those parents who have grown up without parental role models. 42– 44
The problem of keeping the child or children in mind while caring for the ill parent has been identified in both international and Australian service reviews. 45 ,46 Practitioners have noted that it has been easy to lose sight of the roles and needs of different family members in the struggle to respond practically and therapeutically to the need of the ill person. Reder and Duncan, in a review of child abuse and parental mental health, suggest that the core implication of the review is the need for everyone to ‘think family’ and to consider the mutual influence between children and parents. 47
IMPLICATIONS FOR POLICY AND RESOURCE DEVELOPMENT
Following the release of the Children of Parents Affected by a Mental Illness Scoping Project report in 2001, 5 the Australian Government allocated funding for a 3 year initiative to promote better mental health outcomes for children of parents with a mental illness. The Children of Parents with a Mental Illness (COPMI) project goals include the development of good practice principles and action guidelines for services, professionals and other workers, the development of resource materials for professionals, parents and young people, and the provision of advice to government.
Consultations with parents, carers, young people, professionals and other service providers were undertaken in 2002 in association with an extensive literature search. A discussion document was subsequently developed and circulated widely with responses actively sought. 46 A resultant ‘Draft Principles and Actions for Services and People Working with Children Of Parents With a Mental Illness’ document was released for comment in April 2003.
In addition, a range of resources for families and professionals has been developed and pilot tested, including a website for people working with families affected by parental mental illness, and booklets for families. The final Principles and Actions document and associated resource materials is scheduled for release this year. 48
The COPMI initiative and the Royal Australian and New Zealand College of Psychiatrists
The importance of ensuring that psychiatrists contributed to the initiative was recognized at an early stage of the COPMI project. Active involvement and contributions from psychiatrists on the project's Reference Group and National Consultation Group has helped inform the development of resources and recommendations. A subgroup of psychiatrists from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Strategic Planning Group for Private Psychiatric Services (SPGPPS) is assisting in increasing awareness among psychiatrists of both the project and the needs of parents with a mental illness and their children. The RANZCP is also considering developing a position statement.
Opportunities and implications for psychiatric practice
A number of opportunities and implications for practice relevant to psychiatrists and psychiatric teams has been identified. For example, psychiatrists should know which patients are parents, support their patient's parenting role, work in partnerships to enhance child safety and welfare, facilitate prevention and early intervention and be familiar with legal and policy frameworks.
Psychiatrists are invited to read the COPMI Principles and Actions document (downloadable from http://www.copmi.net.au), and the Royal College of Psychiatrists paper ‘Parents As Patients’ (downloadable from http://www.rcpsych.ac.uk/) for further information regarding implications for practice.
Recognition of parenting as a mental health issue
Psychiatrists and psychiatric teams have a key role to play in the implementation of ‘whole family’ approaches to ensure greater recognition of the tasks, responsibilities and experiences of parents, and enhance adaptation by those living with a parent who has a mental illness. Child and adolescent mental health professionals, with their experience in working with individuals in the context of their families and their knowledge of both mental illness and child development, have a lot to offer. However, those working with adults also have a key role in supporting and implementing the changes required in systems and in practice to accommodate a greater emphasis on families.
For example, adult psychiatrists and other mental health professionals and services could:
encourage families and parents to talk with their children about the mental illness and provide materials to parents to assist them to do so (e.g. provide information for children at levels commensurate with the child's cognitive and reading age); assist in answering the children's questions; assist in promoting positive contact between children and parents in their settings by designating areas within their facilities where children and parents can spend time together in a safe environment; facilitate a systematic identification of the parental role of their patients, any concerns their patients have about parenting and the potential needs of their children; ensure that they have access to current information regarding local community child and family health and welfare services, which could support the parent, family and/or children; give greater prominence to the role of parenting within the rehabilitation framework, especially in assisting parents to resume their parental role following a hospital admission;
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acknowledge the caring role that many children and young people provide for their parents by seeking out their views and concerns;
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and promote the parent's insight into their illness and its implications for their family.
Prevention and early intervention
Evidence about the role of early adversity in later susceptibility to psychiatric disorder highlights the opportunity that psychiatrists have to improve individual functioning, reduce current psychosocial morbidity and psychiatric disorder and, in turn, positively influence the quality of life for those who continue to experience difficulties into adulthood and parenthood. 3
Prevention and early intervention approaches include:
the implementation of programmes that increase positive interaction between parents and children and their understanding of the illness (e.g. Beardlsee et al. provide evidence of the effectiveness of two family based preventive intervention programmes for children of depressed parents 51
assisting parents to build upon their strengths and act upon areas of concern in caring for their children;
referring parents to child and family support services within the community;
assisting family and community service providers to tailor their services to meet the needs of parents with a mental illness and their children;
providing assistance to people with a mental illness who intend to have children or who are currently pregnant to access early ante-natal care and to prepare for the care and support of their infants; 52 and
supporting parents' access to family planning advice.
Supporting parents, protecting children
There is a major role for mental health professionals to work collaboratively with child protection agencies, other health and education professionals, and the consumer's family to assess the short- and long-term effects of parental illness and its treatment on a child, where the child is identified as being at risk of harm. 21 ,34 With child protection services taking the lead role, the mental health and justice sectors can work together to support the care and protection needs of children by ensuring that advice/evidence regarding the assessment of parenting competence of individuals with a mental illness is based, where possible, on a child-focused approach, incorporating:
child'-parent observations in natural settings over a period of time, acknowledging the often episodic nature of mental illness;
the linking of specific qualities and functional aspects of parental behaviour with protective or risk factors for the child; and
a multimethod, multisource approach that includes information from a range of experts including mental health professionals who are familiar with the parent's mental health status 53 ,54 (the latter can provide information about prognosis, likely natural history, and compliance with biological and other management approaches).
Working in partnership
Where parents with a mental illness experience other problems such as drug or alcohol abuse or domestic violence, communication, coordination and collaboration between a wide range of agencies is an imperative. Psychiatrists also have a responsibility to consult with child protection professionals if there are any concerns about a child's safety or welfare.
The need to work in partnerships more generally is important because of the many service providers that families come in contact with, such as general practitioners, school counsellors, child and family health and welfare services and those in the justice system. Many barriers to working in partnership with others who could or do provide services to family members affected by parental mental illness have been identified such as agency boundaries, confidentiality requirements, lack of knowledge of each other's areas of expertise and lack of resources. 45 However, psychiatric professionals and services can play a lead role in addressing these barriers and developing partnerships.
A recent major study of intercountry comparisons in the welfare field concluded that professionals in the mental health service working with adults who may be parents are at the front line of raising awareness of the needs of these families. ‘In order to offer services to families that may prevent problems, or prevent problems from escalating, it is necessary to be aware of their needs’. 45 Individually and collectively, psychiatrists can advocate for improved services for these children and families.
Education and training
Throughout the COPMI project consultations, many providers of psychiatric care to adults reported that they feel ill prepared or unsupported to implement a ‘whole family’ approach. The RANZCP members working with the COPMI project will endeavour to ensure that issues highlighted by the project are covered in the academic and clinical education of trainees. The continuing education of psychiatric professionals in this field is also required to further enhance College members' skills in offering family sensitive practice.
CONCLUSION
In his 2001 RANZCP Presidential Address, Jonathan Phillips urged the College to move forward together in the development of health policy with patients and carers and the medical organizations. 55 The COPMI initiative has provided the College with an opportunity to do this with a range of professional partners to improve outcomes for children and young people whose parents have psychiatric disorders.
AUTHOR'S NOTE
Further practical resources such as a website for workers and booklets for families will be available from the COPMI project (http://www.copmi.net.au). If you wish to receive regular updates about the project, please contact. Email: