Abstract
Over five million children in the United States have a parent living with a serious mental illness. These offspring are at higher risk for developing mental health problems themselves due to a complex interplay of biological, psychological, and psychosocial factors. Life with a parent with psychiatric symptoms can be scary, confusing, overwhelming, and sad; children often blame themselves for their parent’s problems, find their parent’s behavior embarrassing, and struggle to explain the illness to their friends. Unfortunately, these children’s needs and experiences are often ignored by overwhelmed parents, worried family members and relatives, separate mental health systems of care for adults and children that often fail to coordinate care, and even well-intentioned health-care providers. Family medicine teams have an opportunity to detect and support these families in unique ways. We offer four recommendations for family medicine teams to help families managing parental mental illness including assessing functioning, treatment needs, and impacts on each family member; educating all family members about mental illness; instilling hope, noting the range of effective treatments for mental illness; and encouraging the use of supports and referral options. Providers can leverage family members’ strengths, work with community-based resources, and offer continuity to these families, as they struggle with an oftentimes chronic, relapsing disease that has ripple effects throughout the family system.
Approximately one in five mothers with children under age of 18 years have experienced major depression. 1 As major depression is more prevalent among families living in poverty, it is estimated that about half of low-income mothers experience depression. 2 Rates of parental anxiety disorders may be even higher than depression. 3 Furthermore, approximately 15 million Americans with at least one biological child will have post-traumatic stress disorder (PTSD) at some point in their lifetimes. 4 The Center for Disease Control has included parental mental illness as one of the adverse childhood experiences (ACEs) that is being regularly assessed in large samples across the country and which are collectively demonstrating significantly elevated risks for numerous adverse outcomes. 5
In light of these statistics, it is estimated that well over five million children in the United States have a parent with a serious mental illness (SMI) which includes schizophrenia, bipolar disorder, and major depression. However, to date, these children and families have received little attention. British child and adolescent psychiatrist, Alan Cooklin, MD, described the situation as such: “Children with a parent with mental illness often fall through the cracks and are seen as nobody’s responsibility. Nothing is explained to them, and they often receive no help at all . . . These children need to be seen and heard.” 6 Evidence suggests that individuals with mental illness are most likely to seek treatment first in primary care. 7 Family physicians and their interdisciplinary team members have a tremendous opportunity to see and hear these families.
The purpose of this article is to describe the impact of parental mental illness on children and to outline ways for family medicine physicians to assess and intervene.
Impact of parental mental illness on parenting and youth
Family physicians recognize that when one person in the family experiences difficulties, everyone is affected. Young family members of parents living with psychiatric problems often assume adult responsibilities and experience uncertainty, anger, shame, sadness, and fear, asking “What is this all about? Why is it happening to me? How can I make my parent all better? Will I be like my parent some day? What do I tell my friends?”
Parents with PTSD and other mental illnesses report more parenting problems, lower parenting satisfaction, more family violence, and poorer parent–child relationships than parents without psychiatric issues.4,8 In comparison to their nondepressed counterparts, depressed parents display less empathy and affection with their children, demonstrate poorer emotion regulation and monitoring of their children, have poorer coparenting relationships, and experience lower self-efficacy as a parent.9,10
Sometimes parents living with mental illness act in confusing, upsetting ways, such as during times of active psychosis. Parents with difficulties dealing with strong feelings may explode in anger which can scare the child. Parents living with mood disorders may struggle with suicidal thinking and behavior, which can be very distressing. When parents act in these ways, children often feel anxious, ashamed, sad, and angry. The parent living with SMI may also emotionally detach (intentionally or unintentionally) from the child. Parental hospitalization and other separations from the parent can disrupt the parent–child bond. Particularly with PTSD, many parents develop emotional numbness which also interferes with the development of close relationships. 11 Detachment, physical separation, and emotional numbing can directly impact the parent’s ability to engage the child in everyday activities. Confused by the parental unavailability, children often feel uncared for, unloved, left out, and lonely. Children may also blame themselves for the confusing behavior in their parent.
Growing research has consistently documented an array of negative outcomes for offspring of parents living with mental illness. A recent meta-analysis found a medium effect-size between parental PTSD and increased rates of child emotional distress and behavioral problems. 12 Similarly, a meta-analysis of 193 studies found associations between maternal depression and both externalizing (acting out) and internalizing (depression and anxiety) problems in children. 13 Rates of child psychiatric diagnosis among offspring of depressed parents range from 30% to 50% (vs. 20% in general population). 14 These children are more likely to experience developmental delays, poorer school performance, and problems with peers than children whose parents do not have mental illness. 15 Importantly, longitudinal research of offspring of parents living with mental illness has documented that these outcomes often persist into adulthood, even at 10-year follow-up. 16
In general, child outcomes relate not only the parent’s illness but also a wide range of other factors, including the child’s coping skills, the family’s socioeconomic status, the level and quality of social support, and access to treatment. As large numbers of parents with SMI lose custody of their children, the changes in living arrangements and family configurations can also affect child functioning. 17
It is important to note that children growing up with parents with SMI can also develop valuable personal strengths. For example, adults reflecting on their upbringing in this family situation have described enhanced awareness of their own compassion, sensitivity, resourcefulness, strength, and independence. 18
Reasons for the neglect of families managing parental SMI
The family experience of parental mental illness has been neglected for many reasons. First, many health-care providers working with adults living with psychiatric issues fail to ask about the existence of children, experience of parenting, or the impacts on children; this neglect has even been found among mental health-care providers. 19 Providers may fail to explore this area due to insufficient time and competing demands, lack of knowledge about how to assess and support these families, concern about potential mandated reporting obligations if abuse is suspected, and a (perceived) lack of relevant local resources.
Second, parents and children may keep family struggles a secret due to stigma, shame, other medical priorities, hopelessness, perception that resources do not exist, and a fear of being reported to child protective services and losing custody of their children. The risk of loss of custody is substantial, as approximately 70% to 80% of parents living with SMI lose custody of their children at some time during childrearing. 17
At a systemic level, the current arrangement of most mental health care separates treatment of adults and children. Youth and adult psychiatric providers often do not even know each other. The facilities may be geographically distant from one another. Funding sources are often distinct. Collaboration of treatment for a family is rare. Sadly, this arrangement creates a gap in care and perpetuates the problem of minimal attention to parenting and these children.
Outcomes
This paper was presented as a Clinical Practice Update at the 2017 Forum for Behavioral Science in Family Medicine in Chicago, IL. This annual conference strives to stimulate progress in the role of behavioral science in family medicine programs; it is sponsored by the Department of Family Medicine of the Medical College of Wisconsin and is endorsed by the Society of Teachers of Family Medicine. Participants in this session expressed high levels of interest in the topic of families impacted by parental mental illness. Several senior physicians anecdotally remarked that they had never thought about the experience of these children and were motivated to now assess this issue with their patients and educate their residents.
Two interesting suggestions were posed during the workshop at The Forum. First, audience members proposed that we include mental illness in the family as a reason for referral on our behavioral health referral; including this option may stimulate referrers to consider this issue in their patients. Another workshop participant suggested that we couch our resident didactic sessions surrounding parental mental illness in the ACE research; given the popularity of this research and the inclusion of “household mental illness” in the Behavioral Risk Factor Surveillance System assessment, residents may come to conceptualize parental mental illness as similar to other important risk factors.
Future directions: Opportunities for family medicine
In light of the high rates of parental mental illness, the demonstrated adverse effects of SMI on both parenting and offspring, and the commitment of Family Medicine to systemic, holistic interventions, we have an opportunity. These families should not be invisible and suffer in isolation. We need to identify, support, and serve the entire family unit.
Of particular note to family physicians, parenthood can be a powerful motivator for patients to take care of both their physical and mental health. Being a parent can provide a sense of purpose and meaning in life and can motivate patients to take care of their health and use healthy coping strategies. 20 Thus, health-care providers can leverage patients’ commitment to their children to engage in healthy behavior.
In working with these families, it is vital to actively look for and highlight strengths in each family member and in their circle of support (e.g., relatives, church, mental health-care providers). As noted earlier, many families have kept these struggles private for years, so they are demonstrating courage in sharing their pain and asking for help. Although the family may be at a crisis point when they come to the office, providers can validate the strength it took for them to ask for help. Behaviorists, care coordinators, and patient advocates can be invaluable resources in working with these families, facilitating referrals to more intensive care, forging alliances with school personnel, working with child protective services when appropriate, and strengthening the structure around these families where they live, work, and play.
We offer the following four recommendations for family physicians and allied health-care providers when working with families dealing with parental mental illness, including assess and listen, educate, instill hope, and encourage use of supports and provide referrals.
Assess and listen
Health-care providers can be emotionally present and supportive to these youth and their families, providing a confidential, accepting environment. Listening to and validating families as they share their experiences while simultaneously withholding judgment can be deeply appreciated. Making time to be emotionally available and providing a supportive, listening ear can be invaluable. With appropriate releases of information, providers should also gather assessment information from and maintain ongoing communication with family members and other professionals in the family’s life (e.g., mental health professionals, teachers) who can provide collateral information and additional supports.
Providers should consider a “two-generation strategy” whether working with parents, children, or entire family units. In this strategy, attention is given both to the at-risk children and to the caregiving adults who can equally benefit from supports and resources. 21
Specific assessment questions may include the following:
For parents with SMI: Do you have children? If so, how are they doing? How does your [insert mental illness here—or simply name symptoms] affect your ability to be the kind of parent you want to be? And, how does it affect your relationship with your children? For children whose parent has an SMI (adapted for child’s specific developmental stage and cognitive understanding): How are things going at home with your parent(s)? What’s toughest for you when your parent is struggling? What’s it like for you when your parent is having a tough time? What’s your understanding of your parent’s illness? Who can you talk to when things are rough at home? For all family members: Who can you turn to when the family is having a tough time? Who can help with the children during times of crises? What does your family do together that is fun? How do people in this family support one another when times are tough?
Given the heightened risk for postpartum depression among women with preexisting mental illness and perinatal depression, family physicians should routinely screen pregnant women for signs of mental illness. Early assessment and detection of mental illness may allow for timely referral to more intensive services.
Educate
Family physicians may be the only health-care professional these families encounter. Although working with families with multiple layers of complex challenges can feel overwhelming for the health-care team, offering families small chunks of basic information can be very helpful. People (children especially) fear what they do not understand, and ignoring the proverbial “elephant in the room” usually creates more problems. Helping families talk openly about their struggles instead of perpetuating the secrecy and shame that often surround mental illness can be useful. Honest, simple information can be conveyed in numerous formats, including handouts and resources in waiting rooms and patient exam rooms, on TV monitors in clinics, and via websites. However, directly engaging the family in discussion during appointments is usually most impactful.
Specific messages to impart to children of parents living with mental illness include the following:
You are not alone. Many families have a parent with a mental illness.
Your parent is dealing with (insert symptoms or name of illness; depending upon the child’s developmental level, sometimes simple words like “a lot of sadness” is sufficient).
- You didn’t do anything wrong. You did not cause your parent’s illness.
- You cannot cure your parent’s mental illness. However, finding ways to express your love and care (e.g., hugs, loving text messages) can mean a lot to your parent!
- Just like with other health concerns (e.g., diabetes), there are a lot of helpful treatments for your parent.
Family medicine teams may also empower patients with written resources to help them understand and cope with parental mental illness. Although resources are limited, some examples include the following:
Veteran’s Guide to Talking With Kids About PTSD. A 25-page free interactive pamphlet for adults about talking with children about parental PTSD. Although written for veterans, most of the information applies to all kinds of parental PTSD. Available for download: www.mirecc.va.gov/VISN16/docs/Talking_with_Kids_about_PTSD.pdf Wishing Wellness: A Workbook for Children of Parents With Mental Illness. Clarke (2006). New York: Magination Press. I’m Not Alone: A Teen’s Guide to Living With a Parent Who Has a Mental Illness. Sherman and Sherman (2006). Edina, MN: Beavers’ Pond Press (www.SeedsofHopeBooks.com).
Instill hope
Regardless of the specific messages, resources, and family situations, health-care providers should instill hope in families dealing with parental mental illness. Given the relapsing course of many SMIs and the potentially serious toll on many aspects of individual and family functioning, families often experience hopelessness and despair. Parents can be repeatedly hospitalized, relapse with substance abuse, engage in frightening self-harm behavior, struggle to find effective medications, and even lose custody of their children. Maintaining a positive, supportive presence (despite inevitable setbacks) and continuing to advocate for everyone in the family can provide a lifeline for these families. Therefore, it is important to repeatedly remind all family members that many effective treatments exist for mental illness and that the health-care team is here to support them across time.
Encourage use of supports and provide referrals
Some families have a strong community of natural supports, including extended family and friends, church organizations, peer support programs such as 12-step programs or services through the National Alliance on Mental Illness, and community groups. In these situations, encouraging families to stay connected to their support network, especially during times of crisis, may be helpful. Requesting the parent sign a release of information to allow you to collaborate with external providers may be a wise proactive strategy to coordinate care. However, some families living with parental mental illness are isolated. All family members may be so focused on the parent with the illness that the children’s emotional and physical needs are ignored. Family medicine teams can encourage the parents or caregivers to connect their child with positive activities and people outside the home.
Although natural supports can be extremely beneficial, many families managing SMIs will be best served by long-term participation in formal mental health care. As being an effective parent can be a motivator for some people living with mental illness, it can be helpful to emphasize to parents that the best thing they can do for their children is to take care of their own mental health. Numerous effective treatments exist for all SMIs, and consistent parental engagement in psychiatric care can provide much-needed stability for the entire family.
Several evidence-based interventions exist for depressed mothers and their children including individual therapy and medications for the parent. 22 For example, a recent meta-analysis found that psychotherapy for depressed mothers resulted in not only reduced levels of depression in the mothers but also significantly improved mental health in children, better mother–child interactions, and less parenting and marital distress. 23
Family medicine teams can also encourage parents to connect their children with mental health professionals. Growing research working with at-risk children has shown that relatively short-term cognitive–behavioral interventions (and sometimes psychiatric medications) can considerably improve children’s well-being and may prevent the development of serious mental health problems. 24
Beyond individual services for parents and children, some family-based approaches appear promising for these families. An example of a comprehensive, integrated In-Home Cognitive Behavior Therapy (IH-CBT) program for depressed mothers involves enhanced home visitor services which help parents overcome barriers to engaging in care. 25 Evaluation of IH-CBT has demonstrated numerous positive outcomes (e.g., decreased depression, increased social support, and increased satisfaction as a parent). Implementation is being facilitated by the Moving Beyond Depression program (www.movingbeyonddepression.org), and the program is currently available in nine states. Programs such as IH-CBT strive to simultaneously reduce parental depression and enhance parenting skills.
In summary, children of parents living with mental illness are significantly impacted, but their challenges and experiences are often not addressed. It is time that these children’s needs no longer “fall through the cracks” and be seen as “no one’s responsibility.” 6 Family physicians and allied professionals have a tremendous opportunity to assess the needs of these children and families. Having an up-to-date list of trusted referral sources for these families can be invaluable when encountering a family in crisis. Family medicine health-care teams can provide education, support, and referrals to improve coping and quality of life in children and families managing parental mental illness.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.