Intervention can begin from the moment an individual seeks professional help.
Using a family-focused approach, and supporting parents to develop practical strategies to promote resilience in their children, can aid parents’ recovery and promote the optimal emotional wellbeing of their children.
We suggest a family-orientated therapeutic approach relevant to the general-practice setting, with particular consideration of the value of communicating with children according to the child’s stage of emotional development.
This is a republished version of an article previously published in MJA Open
Children of parents with mental illness have an elevated risk of psychological problems.1 Associated risk factors include genetic predisposition, the parent’s difficulties in fulfilling a parenting role due to the illness and/or treatments, social isolation, emotional distance or hostility, poverty, conflict between parents, and a chaotic family life.2 Children’s risks can be mitigated by protective factors such as the positive influence of a mentally healthy caregiver and the provision of interventions to reduce the negative factors impacting on the child.1
The number of parents with a mental illness is substantial.3 However, the identification and provision of support to these families is challenging. Identified barriers include low rates of help-seeking for mental illness,4 parents not disclosing their caregiving responsibilities due to the perceived stigma of mental illness,5,6 and lack of insight by parents into the impacts of their illness on their children.7
Many Australians who seek professional support for mental illness approach their general practitioner.4,8 Therefore, GPs are in a prime position to assist patients and their families. Similarly, when parents seek help for their child, the GP can opportunistically discuss parenting challenges and the possibility of associated mental health difficulties.
The parent’s diagnosis and severity of illness are poor predictors of the potential impact on children — more significant is how the illness affects the parent’s behaviour and relationship with his or her child.9 The child’s current age and needs, and his or her age at onset of the parent’s problems play a significant role.2 Parenting responsibilities may also affect the mental health of the parents.10 Therefore, considering the family as a whole can both promote the parent’s recovery and the child’s resilience.1
Rob is a 45-year-old man. His partner Anne, aged 39 years, gave birth to their second child Elise 6 weeks ago. Baby Elise is “so healthy and happy”, says Rob, “but Anne has postnatal depression and she’s not coping with the lack of sleep”. Anne is irritable and struggling with everyday tasks. Rob is worried because their 5-year-old daughter Jade is “acting up”. Jade is clingy and irritable when Anne is focusing on baby Elise, and if asked to wait, throws the baby’s toys in the bin. Rob and Anne know Jade just wants her mother’s attention. Rob feels frustrated: “Between caring for the baby and getting the housework done, we just get Jade out of ‘time out’ and she is doing something else!”
Diane is worried about her 14-year-old son Adam because he is too unwell to go to school several times a week. “I’ve asked him what’s wrong and he says he’s too tired. Last week I made him go anyway but the school called me to pick him up because he’d had a fall and hit his head. When we got home, he told me he’d actually got in a fight with another kid at school and didn’t want to go back ever.”
Diane is feeling overwhelmed, as she is already struggling to support her husband Tom: “Tom’s been really down since he was made redundant at work recently”. Tom is seeing his GP but “he’s still not well. He used to take Adam for a regular kick of the footy when he got home from work so I could get tea on. Now Adam is either hiding in his room or arguing with his Dad at night! I don’t know what to do!”
A key theme in these case studies is that of the child “lost” among the stress of parents dealing with their own issues. A useful therapeutic approach to support these families is presented in detail below and summarised in the Box.
In general practice, key information often lies “in the shadows” of the presenting problem. For the parent with a mental illness, a “wide-angle lens” approach is required. This considers the parenting role of the patient and assists the practitioner and the family to understand the interplay between the parent’s mental health problems and family life. A useful tool is a family genogram, which includes stepchildren, deceased children, miscarriages, previous parent partners, and close family supports.11 This will take several visits and evolves as the patient feels more secure and the therapeutic relationship develops. For example, Rob later discloses that his stepson Mark lives with Rob and Anne on alternate weekends and is also affected by Anne’s depression.
Exploring the familiy’s dynamics and wider social supports highlights the needs and resources of family members. The GP can facilitate the inclusion of a relative or a trusted person outside the family to provide emotional and practical support. For example, is there someone else who can kick a footy with Adam? Can a local playgroup help Anne and Jade find some special time together? The GP can also assist by encouraging parents to consider community supports. Examples include playgroups, council youth programs, parenting support groups, and community mental health support services.
Better outcomes for the child begin with assisting parents to understand the impact of their mental health on their parenting, and the impact of parenting on their mental health.12 Parents need support to explore these links, and it is important that acceptance of mental health problems by an individual is linked with a positive sense of self or it can result in internalised stigma (“I’m so useless; I’m even ruining my kid’s life!”). The goal is for parents to recognise their illness, and its potential impact on others, without feeling disempowered, blamed or worthless. Encouraging parents to seek support and information for their health (and for their parenting if necessary) not only assists the child but also strengthens the parent’s motivation for recovery.13 A recent study found that as a parent’s understanding of mental illness develops, feelings of guilt and shame decrease and children report less anxiety.14 Therefore, the GP can:
provide information about the patient’s condition and how it may impact on parenting, while exploring ways parents can minimise the impact of their illness on their family life;
discuss the strengths and resources that the patient already has;
highlight that the challenges of parenting are common and any illness can exacerbate these. Drawing links between the challenges faced by parents with other illnesses (eg, severe arthritis) can “normalise” parents’ concerns. This can neutralise parental self-blame and promote a more objective approach; and
maintain awareness that the GP does not hold all the answers and that ideas developed by the patient and the family themselves can be the most powerful and long-lasting.
For example, in case study 2, Tom and Diane learnt to recognise the influence of Tom’s depression on Adam’s behaviour and were praised for seeking help. Insight and affirmation were combined with strategies for strengthening Tom’s key role in Adam’s life, and Tom started kicking a footy with Adam in the evenings again. Later, when Tom’s illness prevented him from identifying further small positive steps, the focus shifted to managing Tom’s depression while ensuring that Diane and Adam accessed their own supports during this time.
Exploring mental health issues in the perinatal period, and providing quality advice and care if problems are detected, can reap long-term benefits for children and their families.15 In addition, assessing any potential risk to the child of neglect or abuse, and arranging for supports to be put in place, is a useful prevention strategy. In extreme circumstances (eg, a parent with a long-term psychotic illness, who is not responding well to medication), arrangements may need to be made for the child to be temporarily removed from the immediate care of the parent. In such circumstances, don’t be afraid to ask pregnant mothers what they want for their child when it is born. The parent with insight is often relieved and grateful to know that a safety net can be put in place in the event that they become very unwell.
GPs can draw on their inherent skills as an educator, counsellor and carer to support all family members to communicate about parental mental illness. When more focused or specialist intervention may be required, GPs can also refer a patient and his or her family to specialist mental health services and educational supports such as Children of Parents with a Mental Illness (http://www.copmi.net.au).
With practice, and some knowledge of child development, GPs can facilitate discussions about parental illness with children. For example, 5-year-old Jade mentions “Mum’s doona days”. Asking her what happens on these days and how she feels allows gentle exploration of her understanding and experience of her mother’s illness: “It’s sad all around”. Fourteen-year-old Adam described it as “all too lonely”, and found fact sheets and video-blogs from reputable websites such as beyondblue (http://www.beyondblue.org.au) and itsallright (http://www.itsallright.org) helpful: “It’s good to know I’m not alone”.
GPs can encourage parents to talk with their child about parental mental illness and highlight opportunities for communication and reflection that are present in everyday activities, such as storytelling and play. Storybooks, such as the classic Dr Suess’ My many colored days, can assist the parent and child to explore and reflect on emotions together in the comforting and nurturing zone of storytime. When promoting the use of books and play, it is important that the GP highlights that each child is different, so parents can confidently be guided by their knowledge of their own child’s language and favourite ways of interacting. Some examples GPs can share with parents include:
Does the child love to talk things over? Jade and Anne used to have a “special chat” every afternoon before Elise was born. When Anne re-established this activity, Jade’s behaviour improved dramatically. A teenage child might prefer talking to his or her parent in the car or on a walk around the block for “one-on-one” time.
Does the child prefer sitting quietly and drawing? Ask the child to draw a picture of his or her most and least favourite things and reflect on these pictures with their parent. The older child may prefer to write a story about another child in a similar situation or start a diary.
Is the child a little superhero who loves saving the day? Talk about how even superheroes get sick and time helps them recover. For an older active child, drawing on sporting figures the child identifies with can be invaluable.
The general-practice setting provides opportunities to identify and support families when a parent has a mental illness. GPs can support these families by promoting treatment for the parent, providing information on parental mental illness to family members, and encouraging family communication about parental mental illness. Small positive steps, derived from and planned by the family, can be initiated under the guidance of the GP, who can closely monitor and encourage their progress. Gradually, larger and more far-reaching goals can be planned, and the GP can facilitate access to specialist services, preventive interventions and social supports.
Key messages for general practitioners assisting parents with a mental illness and their familes
The general-practice setting is well placed to identify and provide support for children and families when a parent has a mental illness
Get to know the family of the parent with a mental illness and understand their unique concerns, challenges and strengths, to help harness resources to build the family’s resilience
Support parents to explore their parenting achievements, in addition to any impact of their illness on their parenting (and/or their parenting on their illness), to help parents develop their own strategies for promoting the resilience of their children and family
Talk with children about parental mental health problems, in language appropriate for the age and emotional stage of development of the child, and encourage parents to promote opportunities for children to feel safe asking questions about the illness
Older children find it valuable to attend peer-support programs or visit websites for families affected by mental illness
A list of local programs and services, and a range of downloadable resources for general practice, are available from the Children of Parents with a Mental Illness website: http://www.copmi.net.au
Provenance: Commissioned; externally peer reviewed.
- 1. Falkov A, Lindsey C, editors. Patients as parents: addressing the needs, including the safety, of children whose parents have mental illness. Council Report CR105. London: Royal College of Psychiatrists, 2002. http://www.londonscb.gov.uk/diary/2008conference/ (accessed Feb 2012).
- 2. Fudge E, Falkov A, Kowalenko N, Robinson P. Parenting is a mental health issue. Australas Psychiatry 2004; 12: 166-171. doi: 10.1111/j.1039-8562.2004.02091.x.
- 3. Maybery DJ, Reupert AE, Patrick K, et al. Prevalence of parental mental illness in Australian families. The Psychiatrist 2009; 33: 22-26. doi: 10.1192/pb.bp.107.018861.
- 4. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing: Summary of results, 2007. Canberra: ABS, 2009. (ABS Cat. No. 4326.0.) http://www.abs.gov.au/ausstats/abs@.nsf/mf/4326.0 (accessed Feb 2012).
- 5. Phelan JC, Bromet EJ, Link BG. Psychiatric illness and family stigma. Schizophr Bull 1998; 24: 115-126.
- 6. Fjone HH, Ytterhus B, Almvik A. How children with parents suffering from mental health dis and avoid stigma. To be or not to be ... is not the question. Childhood 2009; 16: 461-477. doi: 10.1177/0907568209343743.
- 7. Thomas L, Kalucy R. Parents with mental illness: lacking motivation to parent. Int J Ment Health Nurs 2003; 12: 153-157.
- 8. Australian Institute of Health and Welfare. Mental health services in Australia 2006–07. Canberra: AIHW, 2009. (AIHW Cat. No. HSE 14; Mental Health Series No. 11.) http://www.aihw.gov.au/publication-detail/?id=6442468277&tab=2 (accessed Feb 2012).
- 9. Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission. Psychol Rev 1999; 106: 458-490.
- 10. Oates M. Patients as parents: the risk to children. Br J Psychiatry Suppl 1997; (32): 22-27.
- 11. Rempel GR, Neufeld A, Kushner KE. Interactive use of genograms and ecomaps in family caregiving research. J Fam Nurs 2007; 13: 403-419.
- 12. Beardslee WR, Swatling S, Hoke L, et al. From cognitive information to shared meaning: healing principles in prevention intervention. Psychiatry 1998; 61: 112-129.
- 13. Nicholson J, Claylield JC. Responding to depression in parents. Pediatr Nurs 2004; 30: 136-142.
- 14. Solantaus T, Toikka S, Alasuutari M, et al. Safety, feasibility and family experiences of preventive interventions for children and families with parental depression. Int J Ment Health Promotion 2009; 11: 15-24.
- 15. Bakermans-Kranenburg MJ, van Ijzendoorn MH, Juffer F. Less is more: meta-analyses of sensitivity and attachment interventions in early childhood. Psychol Bull 2003; 129: 195-215.
- 16. Solantaus T, Paavonen EJ, Toikka S, Punamäki RL. Preventive interventions in families with parental depression: children’s psychosocial symptoms and prosocial behaviour. Eur Child Adolesc Psychiatry 2010; 19: 883-892.
- 17. Beardslee WR, Wright EJ, Gladstone TRG, Forbes P. Long-term effects from a randomized trial of two public health preventive interventions for parental depression. J Fam Psychol 2008; 21: 703-713.
- 18. Maybery DJ, Goodyear MJ, Reupert AE, Harkness MK. Goal setting within family care planning: families with complex needs. MJA Open 2012; 1 Suppl 1: 37-39.
- 19. Phelan RF, Howe DJ, Cashman EL, Batchelor SH. Enhancing positive parenting outcomes: the Mental Health and Parenting Group Program. MJA Open 2012; 1 Suppl 1: 30-33.
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