Children of parents with mental illness

The mental health of parents can impact on the well-being and mental health of their children, however there are a number of evidence-based interventions and effective preventative steps that can be taken to support parents with mental illness to be the best parents they can be and facilitate their own recovery, as well as reduce risks to children and enhance their resilience. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is concerned that many of these supports are not being accessed due to stigma, lack of awareness and limited availability.

This position statement provides an outline of the factors at play when parents are affected by mental illness, and describes some of the evidence-based approaches that should be available to family and whānau members. It is specifically relevant to psychiatrists, however the information is also intended to inform practice by psychiatry trainees, medical professionals more broadly and other providers of mental healthcare.

Definition

Many children grow up with a parent who, at some point, has a mental illness. Mental illness in parents represents a risk for children in the family and/or whānau. These children have a higher risk of developing mental illnesses than other children. Risk is often heightened due to the ways mental illness can complicate parenting and care of infants, children and adolescents including through reduced emotional availability, changed perception of the child and impaired ability to support child development. These parenting difficulties may be episodic or enduring. Parents with mental illness may experience disruptions in their relationship with their child, social isolation, disadvantage, and the effects of stigma. The emotional sensitivity and responsiveness of a parent is usually a key factor in outcomes for the child. Parental substance dependence in particular considerably increases the risk of poor outcome for the children.

Evidence

It is estimated that an estimated 21-23% Australian children, and 15-20% of New Zealander children live in families with a parent who has mental illness (Maybery et al, 2009; South Island Alliance, 2014; Statistics New Zealand, 2012). Many adult mental health service providers do not, or have only recently begun to, record whether their clients have children. Child and adolescent mental health services (CAMHS) and service providers similarly have low rates of reliably recording whether their clients have parents with a mental illness and how their needs are addressed (Gatsou et al, 2016). Careful assessment and consideration of treatment options for the offspring of parents with a mental illness is required. This can be a particularly complex task when parental mental illness has not been formally diagnosed previously and or/ treatment has not been accessed.

An Australian Infant, Child, Adolescent and Family Mental Health Association (AICAFMHA) initiative, the Children of Parents with a Mental Illness (COPMI) National Resource Centre, has estimated that between 29-35% of mental health service clients are female parents of dependent children under the age of 18. Conversely, parents of clients of CAMHS often experience mental illness themselves. On average 30% of parents initially self-identify as having a mental illness, while more are commonly identified during the course of engagement with CAMHS. Many of these parents are not accessing treatment (Jessop and De Bondt, 2012).

In addition to those children living with a parent with mental illness, there are some children who are separated from their parents while they receive mental health inpatient treatment. In the case of children who have a parent detained in a secure mental health facility, such separation can be prolonged. Overall, hospitalisation is considered one of the most stressful aspects of coping with a parent’s mental illness and ongoing and specific strategies to support children in these circumstances are essential. The RANZCP’s Position Statement 57: Mothers, babies and psychiatric inpatient treatment addresses this issue in more detail.

Children of parents with mental illness have an increased risk of adverse developmental outcomes and mental health problems. The impact on the mental health of the child is determined by a complex interplay of genetic and environmental factors. This includes the age of the child, the nature of their parent’s mental illness, the involvement of other adults in the child’s life, and family/whānau relationships (AICAFMHA, 2005; Beardslee et al, 2011). Risk factors can be bidirectional. Not only do parental behaviours influence child outcome but children’s behaviour influence outcomes for the parent (Beardslee et al, 2011; Rutter, 1990).

Parenting style and parent-child relationship are key factors in the transmission of the risk of depression (Rutter, 1990; Phelan et al, 1998). The stigmatisation of people with mental illness and its negative consequences can affect all family or whānau members, and create a barrier to accessing services and suports (Phelan et al, 1998; RANZCP, 2010).

There is increasing recognition that evidence-based early intervention, prevention and treatment programs can reduce risk of mental health problems in children, including those whose parents have mental illness (RANZCP, 2010; Beardslee et al, 2012; Weissman et al, 2006). There also is evidence to show that mental health treatment for parents, parenting support and family/whānau-focused interventions can improve outcomes for children and reduce risk of intergenerational impacts (Weissman et al, 2006; Swartz et al, 2008; Kowalenko et al, 2012; Beardslee et al, 2011; Reiss, 2011; Reupert et al, 2012; Siegenthaler et al, 2012).

Resilient children tend to have individual, family and community resources that enable them to accomplish age appropriate developmental tasks, actively engage in relationships, and understand their surroundings and their parent’s illness (Beardslee and Podoresfsky, 1998). Research highlights the importance of communication about parental mental illness with children.

Recommendations

• Psychiatrists are in a key position to provide or facilitate access to family/whānau-focused interventions that promote resilience in children and families affected by parental mental illness. Psychiatrists should be involved in the development, implementation and review of good practice in this area.
• Assessments of adults with mental illness should include screening for dependent children. If the consumer does have children in their care the following should be assessed:
  • current circumstances and safety of the child or children
  • capacity of the parent(s) to provide physical and emotional care
  • the parent’s access to appropriate supports and services, and/or willingness to access support if needed
  • the direct effect of the parent’s mental illness, and offending behaviour for those in forensic mental health services, on the child or children
  • the availability of alternative care and support for the child or children.
• Additionally, the following steps should be taken:
  • parents given the opportunity to discuss their concerns about their children
  • provide information to parents to assist them in supporting their children
  • when a parent is hospitalised, children should be contacted
  • consult with parents and family/whānau regarding issues of care and custody and facilitate access to legal advice where necessary.
• Assessments of children, adolescents and youth should include consideration of parental mental health status and the impact of parental functioning on their offspring and, if required, appropriate care coordination to address parental mental health problems and provide support.
• If, during assessment of an adult with mental illness, their child or children appear to have significant difficulties, there should be consultation with and/or referral to CAMHS or other appropriate health services.
• Child and adolescent psychiatrists and CAMHS should prioritise secondary consultations with general and other psychiatrists, adult mental health services and other relevant service providers. They should advocate for appropriate service responsiveness and promote interagency collaboration, particularly with adult mental health services that support recovery, and with non-government organisations.
• Support provided to a parent with mental illness should include regular review of concerns about their children and, when necessary, the provision of parenting assistance and psychosocial support. This would include highlighting the importance of communication within families/whānau about parental mental illness and providing access to necessary resources and services (Siegenthaler et al, 2012).
• Access to family/whānau-focused interventions to promote well-being and prevent mental illness in children should be facilitated where appropriate.
• Child protection issues must be considered when relevant. In Australia, reporting of child abuse and neglect is mandatory in all states and territories by medical practitioners. This process should be managed sensitively and collaboratively with patients and families. In New Zealand, while reporting child abuse is not mandatory, the Vulnerable Children Act 2014 prioritises the identification of vulnerable children and communication between professionals to facilitate child protection (New Zealand Government, 2014).
• Training and continuing education of psychiatrists should facilitate exposure to and familiarity with implementing these recommendations in practice.
• Research into and education about intergenerational transmission of mental illness and interventions that effectively reduce the burden of this should be prioritised (including services system approaches).
• The RANZCP should continue to foster and promote binational policy developments, quality initiatives, workforce development, partnerships, strategic research and other systems initiatives to address the needs of children of parents with mental illness and the needs of parents with children with mental illness.

Additional resources

Children of Parents with a Mental Illness (COPMI) National Initiative, Australia. Available at: www.copmi.net.au/

VicHealth. Reasearch Report on Children at Risk in Families Affected by Parental Mental Illness. Available at: www.vichealth.vic.gov.au/search/research-report-on-children-at-risk-in-families-affected-by-parental-mental-illness

New Zealand Government. Children’s Action Plan. Available at: www.mvcot.govt.nz/working-with-children/childrens-teams/

Ministry of Health, New Zealand. Supporting Parents, Healthy Children. Available at: www.health.govt.nz/publication/supporting-parents-healthy-children

The Werry Centre for Child and Adolescent Mental Health. Children of Parents with Mental Illness and/or Addiction project, New Zealand. Available at: www.werrycentre.org.nz/professionals/current-workforce-projects/copmia

American Academy of Child and Adolescent Psychiatry. Children of parents with mental illness. Facts for Families. No. 39. Available at: namimd.org/uploaded_files/224/Children_of_Parents_with_Mental_Illness.pdf