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Family matters: infants, toddlers and preschoolers of parents affected by mental illness

Nicholas M Kowalenko, Sarah P Mares, Louise K Newman, Anne E Sved Williams, Rosalind M Powrie and Karin T M van Doesum
Med J Aust 2013; 199 (3): S14-S17. || doi: 10.5694/mja11.11285
Published online: 29 October 2013

This is a republished version of an article previously published in MJA Open

Early interventions targeting adverse influences on young children and their parents can improve children’s outcomes

Parenting with depression (including perinatal depression)

Perinatal depression and anxiety (often co-occurring) are common mental health disorders affecting about 10%–15% of women. They may begin antenatally, often relapse, and can have detrimental effects on infant and child development.7 The prevalence of these disorders in fathers is about half that of mothers.8 There is a moderate increase in the risk of paternal depression when the mother is depressed.9

Children of parents with depression

Although there are adverse effects of maternal depression on child attachment,9 mitigating factors have also been identified.14 Children of mothers who have been depressed shortly after birth show more behaviour problems in early childhood (particularly if the depression persists), lower IQ scores in late childhood,15 and elevated rates of affective disorders in adolescence when maternal depression recurs.16 Paternal depression during the postnatal period is independently associated with an increased risk of behaviour and socioemotional problems in Australian preschoolers.8 Psychopathology in fathers is a risk factor for toddlers’ externalising behaviour problems when mothers have been previously depressed, and for toddlers’ internalising problems when mothers have either a history of, or current, depressive symptoms.17

Implications for practice

It is generally assumed that the successful treatment of parental depression is associated with reduced psychopathology in offspring. This is evident for children aged 7–17 years.18 However, recent systematic reviews have found that the treatment of maternal postnatal depression may not be sufficient to improve cognitive development, attachment, temperament and other developmental markers in infants and toddlers19,20 without an explicit treatment focus on the mother–infant relationship.21 There is evidence for effectively treating mild to moderate maternal postnatal depression with non-directive counselling, cognitive behaviour therapy, interpersonal therapy and psychodynamic therapy, and more severe postnatal depression with psychotropics.22 However, these interventions, on their own, have not demonstrated sufficient benefit to infants and young children. Two treatments for maternal depression that may improve infant outcomes are described in Box 1. Identifying paternal mental health problems is an important first step towards appropriate interventions.28

Borderline personality disorder and parenting

Borderline personality disorder (BPD) is a complex mental disorder characterised by difficulties in interpersonal functioning, mood instability and poor impulse control. Rapid shifts between idealisation and devaluation are common, reflecting a poor sense of identity. Relationships can be unstable and complicated. Individuals with BPD may also be anxious, depressed and unable to manage difficult feelings. Self-harm and substance misuse are common.29

The core features of BPD affect parenting capacity. The parent with BPD may have difficulties being emotionally available for their child and in managing feelings of frustration. Early parenting can be disrupted by the parent’s difficulties in understanding their infant’s emotional communication.30 Many individuals with BPD have histories of relationship disruption, trauma, abuse and neglect, and parenting can cause anxiety and bring back memories of the parent’s own early trauma.

Psychosis

Psychotic conditions include schizophrenia, schizo-affective disorder, bipolar mood disorder and drug-induced psychoses. Delusions, hallucinations and thought disorder may be chronic or intermittent, depending on the diagnosis. Symptoms of the illness and associated mood changes, lethargy, lack of motivation and compromised sleep may add to parenting disruption.

Parenting issues

For women with more severe psychotic illnesses (usually schizophrenia), pregnancy outcomes are compromised, with higher smoking rates, less antenatal care and higher rates of prematurity.35 Symptoms of the illness, social adversity and medication side effects can compromise parenting. There may be child protection authority involvement, with an increased likelihood of children being taken into care.5

Implications for practice

Most authors cite a combination of good clinical practice — including accurate diagnosis and a biopsychosocial approach to management of the parental mental illness — with attention to the infant, the parent–infant relationship, and the whole family (Box 2). Evidence for improving infant outcomes is scant. Appropriate care should begin in pregnancy, include consideration of the potential impact of psychotropic medications on parent and fetus, and is best supported by an expert team.38 Following birth, long-term community follow-up from a team including a general practitioner and specialised mental health and family workers is likely to provide benefit.39 Local networks may provide information on pathways to appropriate and specialised care such as specialist mother–baby units integrated with obstetric, perinatal and infant mental health care.40 Advocacy for mother and infant is generally required.41

Conclusion

Much current evidence suggests that the greatest impact of parental mental disorders occurs during the early stages of a child’s life.42 Interventions targeting adverse influences on young children and their parents in the early years can improve child outcomes,43 and are cost-effective.44 Good practice in early interventions that support parents with mental illness and their young children45 offers opportunities to mitigate vulnerabilities and build strengths to optimise the development and wellbeing of the next generation, improve parental health, and enhance family functioning. Significant investment in intervention early in children’s lives is required to achieve these aims in Australia.46

1 Implications for practice: treatments for maternal depression to improve infant outcomes

A home-visiting intervention for depressed mothers and their infants

As part of a nationwide prevention program in the Netherlands for children of parents with mental illness, mothers and infants received 8–10 home visits from a prevention specialist. The intervention aimed to enhance the quality of the mother–child interaction by means of video feedback focusing on maternal sensitivity to the child’s signals and needs. Cognitive restructuring of the mother’s negative thinking, practical support, developmental education, baby massage and behaviour modelling were also included.

Improved mother–child interaction, attachment security and socioemotional functioning were found at 6-month follow-up.23 At the age of 5 years, there were positive effects in children in the intervention group who experienced stressful life events. The data suggest that the early intervention might have served as a buffer against the development of externalising behaviour in reaction to stressful life events.24

With broad dissemination since the initial study, this intervention is offered in 70% of adult mental health centres in the Netherlands. One mother who participated in the study said: “I have learned to read my son Lukas and to enjoy to communicate with him. Before I thought he did not like me and I felt insecure about my parenting.”

Preventing perinatal depression relapse — a mindfulness-based intervention

Mindfulness-based cognitive therapy (MBCT) is one of a number of mental health interventions incorporating mindfulness skills to specifically reduce relapse rates in recurrent major depression.25 A pilot study using MBCT modified for pregnant women26 showed favourable outcomes in reducing perinatal mood and anxiety symptoms with high acceptability. In addition, the practice of mindfulness, which is a way of intentionally directing attention to the present moment with acceptance and non-judgement, develops skills which may assist a parent to be more receptive, open and attuned to their infant and themselves. Mindfulness is closely related to an important capacity in early parenting and the capacity of a mother to reflect on her own and her child’s internal mental experience. Impairment in this capacity is a risk factor for psychopathological conditions in offspring. Extending parents’ mindfulness skills may promote improved relationships via increased emotional regulation and awareness, reduced parental stress, and greater acceptance and compassion for the parent and infant.27


Provenance: Commissioned; externally peer reviewed.

  • Nicholas M Kowalenko1,2
  • Sarah P Mares3
  • Louise K Newman4
  • Anne E Sved Williams5
  • Rosalind M Powrie5
  • Karin T M van Doesum6

  • 1 Department of Psychological Medicine, University of Sydney and NSW Institute of Psychiatry, Sydney, NSW.
  • 2 Faculty of Child and Adolescent Psychiatry, Royal Australian and New Zealand College of Psychiatrists, Melbourne, VIC.
  • 3 Alternate Care Clinic, Redbank House, Sydney, NSW.
  • 4 Centre for Developmental Psychiatry and Psychology, Monash University, Melbourne, VIC.
  • 5 Perinatal and Infant Mental Health Services, Women’s and Children’s Hospital Child, Youth and Women’s Health Network, Adelaide, SA.
  • 6 Radboud University Nijmegen, Nijmegen, Netherlands.



Acknowledgements: 

This project is supported by the Children of Parents with a Mental Illness (COPMI) national initiative undertaken by the Australian Infant, Child, Adolescent and Family Mental Health Association with funding from the Australian Government Department of Health and Ageing. We thank Elizabeth Fudge, Project Manager of the COPMI initiative, for her assistance, and Jennifer Harris for her helpful comments.

Competing interests:

No relevant disclosures.

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