Children of parents with a mental illness and their family relationships

• Author: Vicki Cowling, Hunter New England Area Health Service, New South Wales
  Matthew Garrett, Relationships Australia Newcastle, New South Wales
  
• Series editors: Andrea Reupert and Darryl Maybery (Monash University) on behalf of the Australian COPMI national initiative

Quick facts

• Children of parents with mental illness have identified family relationships as important to them, with one study finding the change children most wanted was ‘improving family relationships’.
• It is important to consider focusing on the individual issues and needs, and distressing emotions of the child.
• Working with parents and children together provides an opportunity for children to express their feelings and for parents to reinforce their emotional connection with them after an episode of illness.
• When talking with children, consider their actual age and development stage, as this will influence the language and concepts used.
• View children and young people as competent and active participants in their interactions with you.

Research summary

Between 29% and 35% of adult clients of mental health services in Australia who are women have dependent children, with data from a U.S. survey indicating that 68% of women meeting criteria for psychiatric disorder over their lifetime were mothers, and 55% were fathers.^1,2 Children of parents with a mental illness have identified family relationships as important to them, with one study finding the change children most wanted was ‘improving family relationships’.³

Family relationship approaches involving the children have focused on education about parental depression, the use of family narratives, and family therapy.^4,5,6

The importance of focusing on the individual issues and needs, and the distressing emotions of the child should also be considered and family work which focuses on strengthening family relationships can address this need. Children have an opportunity to express their feelings, and parents can be encouraged to reassure the child that despite an episode of illness they and the child are still emotionally connected.^7,8

Principles in working with parents and children together

Maintain a strengths based view of families in order to enhance existing relationships and family resources.⁶ Respect the natural hierarchy and structure of the family.⁶ Engage each family member, and validate their views, all are relevant.⁶ Be open with the family about professional responsibilities where risks to the safety of children are identified, and responses that may be made to this.

Engaging children

‘Providing children with the opportunity to talk about their experiences will be a significant contribution to supporting that child’s present and future emotional health. It acknowledges the child as an individual who is… impacted upon by all the factors in their environment.’ (9, p. 188).

The following are guidelines for speaking with children:

• Consider the actual age and developmental stage of the child, which will influence the language and concepts used. Devices such as drawings of the family or sad/happy/angry faces, or puppets, may facilitate engagement with some children.^9,10
• Engage with children by asking about themselves, their school life, and their interests.
• Affirm their feelings – negative feelings, and positive feelings.
• Do not presume to know what the child feels or has experienced, ask ‘When Mum/Dad did that, what was it like?’, rather than ‘You must have been worried/sad…’.¹⁰
• Take time and be prepared to wait for the child to think through responses and to speak their own words.¹⁰ View children and young people as competent and active participants in their interactions with you.

Working together with parents and children – a framework

Family meetings are an opportunity to gain a broad understanding of the family situation including family strengths, which validates the experience of all members.¹¹ Where two workers are involved, decide who will work with the parents and who will work with the children. Meet with parents and children together, then separately to allow the children the opportunity to reflect on their experiences.⁸ Return to the family meeting where children’s concerns can be discussed, and opportunities for change within the family identified for review at future meetings.⁸

Benefits to children and young people

Beardslee and colleagues reported increased protective factors and reduced risk factors for children and young people following a longitudinal study of a family education program about parental depression.⁴

Limitations

Family intervention programs have so far focused primarily on adult family members of the identified client. Significantly more evidence is needed on family interventions in which children are active participants, including (in Australia) interventions for families of Aboriginal and Torres Strait Islander background, and those from culturally and linguistically diverse backgrounds.

Clinical implications

Work with children of clients of mental health services who are parents is an opportunity to engage with the whole family, and enables children to express concerns and issues in a safe and protective environment which may not otherwise exist for them. This approach allows children the opportunity to explore their own worries and feelings which may sometimes be difficult if their parents are present.⁸ The professional can feed back, or support the child to feed back to parents the issues the child wants addressed.

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1.  Hearle J, Plant K, Jenner L, Barkla, J, McGrath J. A survey of contact with offspring and assistance with child care among parents with psychotic disorder. Psychiatric Serv. 1999; 50: 1354-1356.
2. Nicholson J, Biebel, K, Williams VF, Katz-Leavy J. Prevalence of parenthood in adults with mental illness. Implications for State and Federal policy, programs, and providers. In Manderscheid RW, Henderson MJ, editors. Center for Mental Health Services. Mental Health, United States, 2002. DHHS Pub. No. (SMA) 3938. Rockville, Maryland: Substance Abuse and Mental Health Services Administration; 2004. p. 1220- 137.
3. Stallard P, Norman P, Huline-Dickens S, Salter E, Cribb J. The effects of mental illness upon children: A descriptive study of the views of parents and children. Clin Child Psychol Psychiatry. 2004; 9: 39-52.
4. Beardslee WR, Gladstone TRG, Wright EJ, Cooper AB. A family-based approach to the prevention of depressive symptoms in children at risk: Evidence of parental and child change. Pediatrics. 2003; 112: e119-e131 www.pediatrics.org/cgi/content/full/112/2/e119
5. Fredman F, Fuggle P. Parents with mental health problems: Involving the children. In: Reder P, McClure M, Jolley A, editors. Family matters: Interfaces between child and adult mental health. London: Routledge; 2000. p. 213-226.
6. Cooklin A, Gorell Barnes G. Family therapy when a parent suffers from psychiatric disorder. In Göpfert M, Webster J, Seeman MV, editors. Parental psychiatric disorder: Distressed parents and their families. Cambridge: Cambridge University Press; 2004. p. 306-321.
7. Blair K. In a daughter’s voice – A mental health nurse’s experience of being the daughter of a mother with schizophrenia. In Cowling V, editor. Children of parents with mental illness 2: Personal and clinical perspectives. Melbourne: ACER Press; 2004. p. 85-98.
8. Focht-Birkerts L, Beardslee WR. A child’s experience of parental depression: Encouraging relational resilience in families with affective illness Fam Process. 2000; 39: 417-434.
9. Absler D. Talking with children about their parents’ mental illness or mental health problems. In Cowling V, editor. Children of parents with mental illness. Melbourne: ACER Press; 1999. p. 183-194.
10. Cooklin A. Talking with children and their understanding of mental illness. In Göpfert M, Webster J, Seeman MV, editors. Parental psychiatric disorder: Distressed parents and their families Cambridge: Cambridge University Press; 2004. p. 292-305.
11. Hanna S, Brown J. The practice of family therapy. Key elements across models. California: Brooks Cole; 1995.

Resource

• Wilson, J. (1998). Child-focused practice: A collaborative systemic approach. London: Karnac Books.
  Describes a family therapy approach which focuses on the child’s experience while holding the whole family in mind.