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Biological Influences

There is growing support that children of parents with mental illness may be constitutionally vulnerable at birth. Infants of mothers with schizophrenia have been found to be at greater risk for fetal and neonatal death, and more vulnerable to negative consequences resulting from obstetrical complications. Similarly, infants of mothers with depression have shown greater delivery complications, lower Apgar scores, lower tonus and less self-quieting ability. Psychiatric diagnoses are also associated with biochemical dysregulation. Recent investigations have supported the possibility that maternal dysregulation or its effects during pregnancy may influence neuroendocrine dysregulation in infants. This dysregulation may be related to emotional and behavioral functioning during infancy and to the development of later emotional and behavioral problems. For example, studies of depressed, pregnant women have found that levels of hormones associated with depression and stress were abnormally elevated during pregnancy. A single study indicated in addition, that variation of fetal levels of one of these hormones, cortisol, was explained by maternal levels at 20 to 36 weeks of pregnancy. Thus, maternal cortisol levels were related to fetal levels. However, Goodman and Gotlib caution that the link between exposure to neuroendocrine dysregulation and outcomes needs to be confirmed in additional studies, and the link between immediate outcomes and development of later psychopathology needs further investigation.

In addition to neuroendocrine abnormalities, the presence of mental illness during pregnancy may compromise a mother's health behaviors and prenatal care that, in turn, may result in a less nurturing fetal environment and biological transmission of risk. It is important to reiterate that the choices of mothers with mental illness about health behaviors during pregnancy are complicated, and may be as strongly related to stigma and fear of loss of custody, as they are to the presence of mental illness.

Illness Characteristics

The relationship of specific parental diagnoses to child outcomes is unclear. Early studies found no lasting differences on a variety of child outcomes across different diagnoses. However, newborns of depressed women showed worse outcomes on obstetrical status and neonatal autonomic functioning than newborns of women with schizophrenia, causing speculation that children of depressed mothers may be at greatest risk. By contrast, a more recent study revealed that mothers with schizophrenia showed weaker parenting skills than mothers with affective disorders, suggesting that these children may be at greater risk. Most evidence, however, indicates that severity of symptoms, chronicity of illness, and lower adaptive functioning of parents are more closely related to poor child outcomes than are particular diagnoses. Other parental illness characteristics that have been found to be predictive of worse outcomes include earlier age at onset of parental depression (prior to 30 years old), and comorbidity of depression and anxiety.

Environmental Influences

Non-genetic and non-biological factors also play important mediating roles in the transmission of risk for and resilience to psychiatric diagnosis. In particular, research has identified important individual and family characteristics that are associated with parental mental illness and child outcomes. Most notably, these include parenting behavior, marital or partner relationship, and family functioning.

Numerous studies suggest that parenting behavior is affected by the presence of mental illness, and that parenting has a strong influence on child outcomes. Research indicates that mothers with mental illness show a range of difficulty with parenting, and that these difficulties may differ somewhat as a function of diagnosis. Mothers with schizophrenia and affective disorder diagnoses both show decreased verbal and emotional responsiveness compared to well parents. Mothers with schizophrenia appear to express less anger and hostility than either well mothers or mothers with depression, while mothers with depression have been found to express greater levels of hostility that well mothers. In addition, mothers with depression exhibit latent, less contingent responses, increased expression of sadness, and irritability, and less expression of positive emotions.

These parenting characteristics in turn, have been shown to be associated with poorer attachment and developmental delays in language, attention, and social competence among infants and toddlers. Additional work with depressed mothers has indicated that they tend to withdraw from confrontation and conflict with children, rather than engage in negotiation and that depressed affect in mothers may influence decreased expressions of anger by other family members including children. Such parenting styles may influence the development of maladaptive coping styles and interpersonal skills associated with depression and anxiety in children. More research is needed to support links between specific parenting behaviors and specific child outcomes.

Depressed mothers also show differences in cognitive processing from non-depressed mothers. Parents with depression engage in more negative information processing, and are more likely to have negative attribution styles and to evaluate themselves poorly as mothers. Studies have shown that children of depressed mothers have similar cognitive styles and negative self-concepts and that these styles may be somewhat dormant under positive conditions, but can be "turned on" by exposure to situations that raise negative emotions. Thus, depressed parents may be modeling cognitive styles that increase their child's vulnerability to depression.

Unfortunately, there has been no investigation of strengths among parents with mental illness, nor of the potential relationship of these strengths to child outcomes. As noted above, however, parents with a mental illness identify parenting as an important and valued role in their lives, and reflect the same desire as non-ill adults, to be the best parents possible.

Tags: Parenting and Families

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