Having a Parent with Mental Illness, Part 3

by SAMHSA

(Page 11 of 20)

The quality of a marital or partner relationship has been shown to be a strong mediator of the relationship between parental diagnosis and child outcomes. Although research has focused on marital discord as a negative mediator, some recent work indicates that supportive partnerships may contribute to resilient outcomes in children. This phenomenon will be discussed further in the following section on moderators. Marital discord and divorce are more common among families in which a parent has a mental illness, and adversely affect both the ill parent and children. Marital discord predicts a host of child and adolescent problems, including lower academic performance, poor social skills, and conduct problems. Investigations attempting to distinguish between the effect of marital discord and depression have found that discord rather than depression may be the stronger predictor of child problems. Thus, interventions for couples in which one or both parents are depressed may be particularly beneficial for children.

A chaotic home environment, lower family cohesion, increased parent-child discord, and poorer communication are more prevalent among families with a parent with depression or schizophrenia. These features of family functioning are, in turn, associated with increased risk for emotional and behavioral problems in children. In a study comparing different levels of family relationships, Dickstein et al. (1998) found that family-level interactions may be more influenced by the presence of parental mental illness than individual parent-child, or spousal relationships. Thus, risk to children may ensue more from family-level interactions not assessed in prior studies of parent-child relationships. By contrast, parent-child relations may be a relative strength for parents with a mental illness, and a promising avenue for intervention.

Moderators of the Relationship between Parent Mental Illness and Child Outcomes

As described above, moderating variables are factors that do not result from a parent's mental illness, but that can enhance or worsen child outcomes in the context of parental mental illness. Moderators, therefore, may provide particularly fruitful avenues for intervention. As discussed throughout this paper, multiple socio-political factors such as political climate, stigma, and the availability of funding for appropriate programs influence the effects of parental mental illness on children, and the risk for the development of problems among children. Additional moderators of the relationship between parental mental illness and child outcomes include characteristics of the spouse or partner, environmental stressors and supports, child characteristics, and therapeutic intervention.

Spouse or Partner Characteristics

The presence and availability of a supportive spouse or partner has been shown to enhance outcomes for both children and adults in a family in which a parent has a mental illness. In contrast, mental illness and/or substance abuse in the spouse or partner can increase the negative impact of parental mental illness on children both directly, and indirectly, by contributing to increased stress and poorer family functioning.

Environmental Stressors

Chronic and/or acute stressors outside the family can also moderate the impact of parental mental illness on children. More specifically, the stress associated with minority status, low levels of education, single parenthood, social isolation and poverty increases the likelihood of emotional and behavioral problems in children of parents with mental illness. Moreover, in families with a parent with depression where stress was low, support high, and depressive symptoms less severe, significantly fewer children exhibited mental health problems than children from all families with a parent with depression.

Child Characteristics

Initial exploration of the relationship between parental mental illness and child outcomes presumed unidirectional influence, i.e., parental illness affects children. More recent work is revealing that effects may be bidirectional and transactional, with children's characteristics influencing parents' symptoms and behaviors which, in turn, affect children's behavior and functioning. For example, problematic child behavior creates stress for parents that can exacerbate parents' symptoms and/or can elicit poor parenting practices that, in turn, increase child conduct problems.

Child characteristics such as temperament, intelligence, social skills, and cognitive processes have been shown to be important sources of risk and resilience for children. Greater intelligence, and strong interpersonal skills appear to protect children in both the short and long-term from adverse outcomes. Cognitive characteristics such as a positive and coherent self-concept, a positive attribution-style, and effective coping and problem-solving abilities have been associated with good outcomes among children in general and among children with depressed mothers in particular.

Child gender also appears to be an important and potentially complex moderating factor in the relationship of parental mental illness and child outcome. Some studies have shown that girls are more adversely affected than boys by a parent's depression, while other studies have shown that boys fare worse. Studies also show that girls and boys may show divergent responses, with girls more likely to develop depression, and boys more likely to show conduct problems. A recent study further indicated that gender may interact with family functioning such that poor family functioning secondary to maternal depression predicts conduct problems in girls, but not in boys.

The relationship of children's age and exposure to parental mental illness is also unclear. Data indicate that repeated exposure to parental illness and the disruption it can create for children are harmful, events more likely to occur if illness occurs when children are young. This has been supported by a single study that showed worse behavior problems among younger children of parents with depression. However, several studies have failed to find age or developmental effects.

Therapeutic Intervention

An intervention may be targeted to and influence mediating or moderating variables and, therefore, become a moderator in the relationship between parental mental illness and child outcomes. Recent years have seen the development of increasing numbers of programs for parents with mental illness. However, little standardized evaluation data exist for these programs with respect to child and/or family outcomes. Two intervention projects have provided some promising results.

The Thresholds Mothers' Project in Chicago is a comprehensive services program for mothers with serious mental illness and their young children (aged 0 to 5 years). Mothers receive mental health services, parenting education and support. Children and parents attend a therapeutic nursery staffed by child development specialists who work with the children and "coach" the mothers in child development and appropriate play. A five-year study of The Thresholds Mothers Project (Musick et al.) indicated that both mothers and children showed improvement over time. Children evidenced increases in Developmental Intelligence, Intelligence Quotient, social competence and adaptive skills. Mothers' showed enhanced attentional skills, social adjustment, and adjustment to work and parenting roles (Musick et al.). No significant differences in child or maternal outcomes were noted for a comparison of Thresholds' participants and participants in a much less comprehensive home-based aftercare program where participants received weekly visits from a psychiatric nurse or social worker (Musick et al.).

In a second intervention program for families coping with parental affective illness, Beardslee and colleagues provided education to parents and children about the parents' illness and the potential effects of parental mental illness on the family. Results showed that families reported improvements across many areas of behavior and attitude consistent with better child outcomes. These changes included improved family and parent-child communication, increased communication between parents and children about depression, and adoption of new family/parenting coping strategies, among others. Children reported better understanding of parental illness, and better adaptive functioning, however some of the children experienced significant symptoms in the period of observation after the intervention).

SUMMARY: Research on child outcomes has uncovered multiple sources of risk and resilience for children who have parents with mental illness. The majority of studies have focused on white, middle class samples of children of depressed mothers. It is therefore difficult to know whether these same models might be applied more generally across race, class and parental psychiatric diagnoses. In addition, the influence of ethnic and cultural differences is not understood. Within these limitations, studies have revealed that both genetic/biological and environmental factors can be sources of risk and resilience. However, most investigations of resilience have focused on environmental variables. Specifically, studies have revealed that heredity, severity and chronicity of illness, parenting behavior, marital discord, and family relationships are important mediators of the relationship of parental mental illness and child outcomes. Spousal or partner characteristics, environmental stress and support, and child characteristics such as temperament, cognitive styles and interpersonal skills are important moderators. Studies have focused heavily upon sources of risk, and may have missed potentially powerful sources of resilience upon which interventions might be based. Data do not reflect children's subjective experience of parental mental illness, or reports of what children think might be useful. In spite of these limitations, interventions founded upon what is known about sources of risk and resilience have been somewhat fruitful, though few and far between. In particular, efforts to enhance children's understanding of mental illness and parents' understanding of children's needs have shown promising results.

RECOMMENDATIONS: Increased research attention must be paid to strengths and sources of resilience among both parents and children; and to how sources of both risk and resilience relate to ethic and cultural differences. Children must be asked about their experiences of living with parents with mental illness, and their needs. Effort should be made to bridge the gap between research and practice. Current knowledge about sources of risk and resilience should be translated into practical interventions that enhance sources of resilience and mitigate sources of risk. These interventions should be evaluated for effectiveness.

About the Author

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