Pre-school children in families with parental mental illness

• Authors: Vicki Cowling, Child and Adolescent Mental Health, Hunter New England Area Health Service
  Kathryn Thornton, Perinatal Psychiatry Service Hunter, New England Area Health Service 
• Series editors: Andrea Reupert and Darryl Maybery (Monash University) on behalf of the Australian COPMI national initiative.

Quick facts

• A child’s relationship with their parent provides the basis for their social and emotional development.
• Parental mental illness may impact on the relationship between child and parent which can result in insecure or disorganised attachment in the child.
• Interventions may include individual therapy with the child, child-parent therapy, programs for parents, and community based programs such as childcare or pre-school.
• Pre-school children may not have the language skills to describe their observations but they will be aware of their parent’s mental illness, and it is important they know that it is not their fault.
• Family care plans are a practical way to show children that the adults in their world are keeping them in mind, and will take care of them.

Research summary

Pre-school children, 2-5 year olds, comprise 5% of the Australian population.¹ The estimate that 21.73% Australian children live with either one or two parents with mental illness means that approximately 50, 424 Australian pre-school children have one or two parents with mental illness.²

Pre-school child development

The pre-school years are characterised by the emergence of autonomy. Children are becoming more self-reliant, purposeful and self-guided, with expanding social competence and broadening social relationships.³ Their relationship with their parent provides the basis for their social and emotional development.

Pre-schoolers’ development may be affected by parental mental illness

The capacity of parents to provide appropriate care and stimulation may be challenged by mental illness. Symptoms experienced by the parent as well as any effects of medication may directly affect the quality of their interactions with their child which can result in insecure or disorganised attachments, their daily childcare, and routines such as pre-school attendance, or recreational and social outings.^4,5 Where social isolation is experienced, opportunities to interact with and learn from other parents and children are reduced.

Helping pre-school children to understand

Pre-school children may not have the language skills to describe their observations and perceptions, but they will be aware of parental mental illness.^6,7 They need to be included in conversations about what is happening, using age appropriate language which is concrete and provides reassurance, such as, ‘Mummy is taking medicine to help her get better’.⁷ Without this, they may draw their own conclusions, and attribute their parents’ illness to something they have done.⁶ It is important to let the children know that it is not their fault that their parent is unwell, and to give them information that dispels or reduces worry and feelings of helplessness.⁷

Family care plans

Pre-schoolers should be reassured that if their parent is unable to care for them there is someone who will until their parent is well enough. Family care plans are a practical way to show children that adults in their world are keeping them in mind, and can be regularly updated.⁸

Interventions

When there is parental mental illness children should be observed for signs of distress. Behaviours such as withdrawal or acting out, extreme responses to situations, inappropriate familiarity with strangers or an inability to seek comfort from their parent may indicate that the child is being adversely affected and is in need of help. Possible interventions include:

• Individual therapy with the child, accompanied by parallel sessions with the parent for those children who find it difficult to express themselves in front of their parent, as they are fearful of hurting their feelings, or where children are over-reliant on their parents and the parent is overprotective.⁹
• Child-parent group intervention such as the ‘Circle of Security’ (COS).¹⁰ COS is an intervention based on attachment theory, which aims to establish the parent as a secure base for the child. Video vignettes of the children are used to enhance the parent’s reflective capacity and their attunement to their child.
• Community based interventions include parenting programs that focus on enhancing parents’ capacity to encourage their children to talk about their feelings, so they learn that their parents are there to help them understand and manage their emotions; assistance through programs which may include home visiting to support parents in fulfilling their parenting role and to meet the developmental needs of their child; and attendance at childcare or pre-school.^11-14

Limitations

There are many opportunities for further research relating to pre-school children, including the perspective of parents, and of families with preschool children of Aboriginal or culturally and linguistically diverse backgrounds.¹⁵ The role and experiences of partners, and grandparents as carers are two further areas of research that could enhance service provision to pre-school children and their families.¹⁶

1. Australian Bureau of Statistics. Census QuickStats: Australia. 2006.
2. Maybery, D, Reupert, A., Patrick, K. Goodyear, M. & Crase, L. Prevalence of children whose parents have a mental illness in Australia. Psychiatr Bull, 2009; 33, 22-26.
3. Sroufe, L.A., Egeland, B., Carlson, E.A. & Collins, W.A. The development of the person. The Minnesota study of risk and adaptation from birth to adulthood. New York: Guilford Press; 2005. p.121-147.
4. Hill, J. Parental psychiatric disorder and the attachment relationship. In Göpfert, M., Webster, J. & Seeman, M.V. editors. Parental psychiatric disorder. Distressed parents and their families 2nd ed. Cambridge: Cambridge University Press; 2004 p. 50-61.
5. Kelly, M. Approaching the last resort: A parent’s view. In Cowling, V. editor. Children of parents with mental illness. Melbourne: ACER Press; 1999. p. 60-75.
6. 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.
7. Lewandowski, L.A. Needs of children during the critical illness of a parent or sibling. Crit Care Nurs Clin North America, 1992; 4, 573-585.
8. Reupert, A.E., Green, K.T., & Maybery, D.J. Care plans for families affected by parental mental illness. Fam Soc, 2008; 89, 39-43.
9. Lieberman, A.F. & Van Horn, P. Assessment and treatment of young children exposed to traumatic events. In Osofsky, J.D. editor. Young children and trauma. Intervention and treatment. New York: The Guilford Press; 2004 p. 111-138.
10. Hoffman, K., Marvin, R., Cooper, G. & Powell, B. Changing toddlers’ and pre-schoolers’ attachment classifications: The Circle of Security intervention. J Consult Clin Psych, 2006; 74, 1017-1026.
11. Havighurst, S.S., Harley, A., & Prior, M. Building preschool children’s emotional competence: A parenting program. Early Educ Dev, 2004; 15, 423-447.
12. Weininger, O. Time-in parenting. Toronto: Rinascente Books Inc.; 2002.
13. Bisogni, N. Mothers support program: An outreach psychosocial rehabilitation program. In Cowling, V. editor. Children of parents with mental illness. Melbourne: ACER Press; 1999. p. 111-119.
14. Dolby, R. Ebert, C. & Watson, S. Childcare: A ‘holding environment’ supporting infants and their parents with mental illness and emotional difficulties. In Sved Williams, A. & Cowling, V. editors. Infants of parents with mental illness: Developmental, clinical, cultural and personal perspectives. Brisbane: Australian Academic Press; 2008. p. 249-261.
15. Yeo, S.S. Bonding and attachment of Australian Aboriginal children. Child Abuse Rev, 2003; 12, 292-304.
16. Jennifer ‘….No Question’. In Sved Williams, A. & Cowling, V. editors. Infants of parents with mental illness: Developmental, clinical, cultural and personal perspectives. Brisbane: Australian Academic Press; 2008 p. 105-108

Resources

• A booklet for parents of pre-schoolers, and resource for workers called is available in the ‘free materials’ area of the COPMI website: ‘Piecing the puzzle together: Raising young children when mental illness is part of your life.’
• A list of story books for pre-school children can also be found on this website – through the resource library search for ‘infants/toddlers, preschoolers’.