Transcript Parenting with Severe Mental Illness

By: Jennifer Richardson, MA
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The ways in which severe mental illness (SMI)
can impact the family system will be reviewed.
The risks and protective factors to consider in
working with offspring of parents with severe
mental illness will be discussed.
Recommended treatments in effectively
working with parents with SMI and their
families will be reviewed.
Important considerations in working with
children at different developmental stages in
effectively coping with their parents illness.
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Sterilizing individuals with mental illness
Move from state hospitals to the
community
Role of antipsychotic medications in
controlling symptoms
Public education about mental illness has
helped to reduce the stigma and incorrect
beliefs people held about mental illness.
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2/3 of adults meeting criteria for psychiatric
disorders are parents.
Mothers diagnosed with a severe mental illness
(SMI) are just as likely to be parents as those who
are diagnosed with other psychiatric disorders
(Nicholson, Sweeney, & Geller, 1998).
Average age of onset for SMI in women-mid to
late twenties leaves them at increased risk during
a period when many women are more likely to
have children.
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Stress in pregnancy, childbirth, and child rearing
may contribute to development of a mental
illness (Nicholson & Henry, 2003).
Women diagnosed with SMI are at increased risk
for:
1. living in poverty
2. raising children as single parents
3. experiencing marital discord
4. social isolation
5. conflicts with extended family
(Oyserman, Mowbray, Meares, & Firminger, 2000).
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Mental illness often is cyclical with periods of
wellness and periods of illness.
Mothers who reported experiencing high
symptoms, reported high levels of parenting
stress and lower levels of nurturance with
their children when compared to mothers
with SMI reporting low symptom levels
(Kahng, Oyserman, Bybee, & Mowbray, 2008).
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antipsychotic medications used to treat
mood swings and psychosis can have
negative side effects:
somnolence can impact ability to
provide necessary focused attention and
alertness needed to care for an infant or
toddler (Seeman, 2011).
medication non-compliance
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Families with parental mental illness are
considered to be at increased risk for losing
child custody and parents with SMI are often
viewed as incapable of parenting successfully.
Hospitalization of parent due to mental
illness can result in loss of custody.
Parent mental illness can be used in divorce
child custody disputes.
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Family disruption and placement of children
into foster care can be devastating with long
term negative consequences for both parents
and the children (Hinden, Biebel, Nicholson, &
Mehnert, 2005).
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Children of parents diagnosed with SMI are at
increased risk for:
having emotional and behavioral problems
involvement in special education services in
school
lower academic achievement overall
(Craig, 2003; Mowbray, Bybee, Oyserman,
MacFarlane, & Bowersox, 2006).
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Offspring of parents diagnosed with bipolar
disorder have been estimated to have rates
between 40-60% of developing moderate to
severe forms of psychopathology during
childhood or adolescence (Lapalme, Hodgins &
LaRoche, 1997).
In the offspring of bipolar mothers selfregulatory deficits had a greater tendency to
develop into thought problems whereas in the
offspring of major depressive disorder mothers,
self-regulation deficits later resulted in
internalizing problems (Klimes-Dougan et al,
2010).
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A child’s developmental stage and age at the time he/she is first
exposed to maternal depression may be important in
determining future risk.
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Some evidence suggests early exposure to maternal depression,
is more deleterious than later exposure.
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an older child is thought to be less vulnerable to adverse
influences as a result of having more mature behavioral systems.
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The heritability of depression in childhood more strongly linked
to mothers with earlier onset of depression, particularly during
the postpartum period (Goodman & Gotlib, 1999).
attachment style between infant and parent is established early
and the presence of an episode of SMI may increase possibility of
future insecure attachments (Nicholson & Henry, 2003)
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Studies suggest depressed mothers are more
likely to expose their children to negative
cognitions, affect, and behaviors in
comparison to mothers without depression.
children with depressed mothers consistently
demonstrate an increase in maladaptive
cognitions, affect and behavior that may then
increase their risk of later developing
depressive symptoms (Goodman & Gotlib,
1999).
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Risk for suicide was examined by Klimes-Dougan and
Martinez (2008) in a longitudinal study evaluating
suicidal thoughts and behaviors from childhood
through young adulthood in the offspring of parents
with major depressive disorder (MDD) and bipolar
disorder.
Results found:
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offspring of parents diagnosed with MDDincreased risk starting in childhood
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offspring of parents with bipolar disordersignificant increase in risk for and severity of
suicide thoughts and behaviors in young adulthood
but not in childhood.
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According to Mowbray et al (2006) children with
mothers diagnosed with bipolar disorder
reported significantly higher amounts of
problems compared to children with mothers
diagnosed with depression and schizophrenia.
Depressed mothers were found to interact less
responsively to their infants-providing a less
than optimal environment for their babies to
learn effective social communication skills.
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Mothers diagnosed with schizophrenia, other
psychotic disorders, and affective disorders were
more uncertain of their infants’ needs, provided
less social contact, were less involved, and less
able to create positive emotional atmosphere.
In comparing unipolar depression to a diagnosis
of bipolar during the infancy and preschool
years, maternal unipolar depression appears
more detrimental (Oyserman et al, 2000).
Qualitative studies examining risk and
resiliency in children with a SMI parent found
the following traits more common in children
who struggled with adjustment:
1. children who expressed self-blame,
2. took undue responsibility for the parent’s
illness and/or problems,
3. and had little understanding of the nature
of the parents illness (Cooklin, 2008).
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those children who were functioning well:
Were able to conclude they were not the
cause of their parents’ illness which was
crucial to their understanding of what was
happening and to their capacity to deal with
having a sick parent.
had other supportive relationships to turn
to for support to cope during episodes of
parental illness
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Resilient individuals described having a
change over time in how they viewed their
parents’ illness and themselves.
They were able to effectively view their own
futures as separate from their parents and
did not expect for their own futures to be the
same as their parents (Beardslee &
Podorefsky, 1988).
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Resiliency factors important to success of
mothers diagnosed with SMI include having
access to social support. (Mowbray, Bybee,
Hollingsworth, Goodkind, & Oyserman,
2005).
Additionally, parenting has been identified as
having a positive and motivating effect for
many mothers with SMI that helps keep them
involved with treatment (Oyserman et al,
2000).
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The importance of identifying effective
treatments addressing the needs of parents
diagnosed with SMI and their families has
been highlighted throughout when identifying
the many risks these families are facing.
Several different but similar intervention
programs have been examined for
effectiveness but no studies comparing the
different approaches to determine varying
degrees of effectiveness have been examined.
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According to Nicholson, Albert, Gersehenson, Williams, and
Biebel (2009) the Family Options program was developed to
address the unique needs of parents diagnosed with SMI.
goal of the program is to build essential skills, provide
resources and to promote access to both professional and
natural supports.
Interventions are family-centered, strengths-based, familydriven with a focus on recovery and resilience.
Multiple domains are addressed in setting treatment goals
including family relationships, employment and school, child
behavior management, and housing.
Family coaches are available for in home skill building support
as well as 24 hour access available for telephone support.
Both the quantitative and qualitative pilot study data have
supported the effectiveness of the Family Options program.
Hinden et al (2006) reviewed 20 programs being
used to address the needs of parents with SMI
and their families.
 Important key assumptions found across the
programs include:
1. recognition of the common occurrence of
adults with SMI having and raising children.
2. Belief that with adequate supports parents with
SMI can parent effectively.
3. Central goal of preserving integrity of the
family, prevention of disruption and custody
loss.
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important components thought to impact
effectiveness of the interventions include:
1. parent education aspect of the program
2. coordination of care across multiple providers
facilitated by a case manager
3. access to flexible funding for use in
emergencies and to assist in accessing
necessities
4. therapeutic nurseries provided with a focus on
child development.
5. importance of inter-agency collaboration and
need for integrated services across adult and
child service sectors (Hinden et al., 2005).
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Invisible Children’s Project (ICP) was examined in working with
parents diagnosed with SMI who are at risk of having their
children removed from the home.
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ICP is family centered, comprehensive, strengths-based,
emotionally supportive and nonjudgmental.
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Role of the case manager in ICP is to provide coordination of
multiple providers, improved comprehensibility and accessibility.
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Case managers are available for 24 hour problem solving
support.
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Case managers were provided with weekly individual and group
supervision in order to gain feedback from fellow peers as well
as supervision (Hinden et al., 2005).
Brunette, Richardson, White, Bemis, and Eelkema
(2004) reviewed the Integrated Family Treatment
Program in working with parents with SMI and
their children.
 Key components identified include:
1. engagement in treatment
2. assessment
3. linkage to environmental supports
4. parenting skills training using a modeling and
coaching approach.
5. coordination of services for both adult and
child to improve communication.
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Nicholson and Henry (2003) conducted six focus groups with
mothers diagnosed with SMI to explore their needs.
Themes identified in the study included need for assistance:
in accessing essential resources
negotiating the system of entitlements
understanding eligibility requirements for supports
In child behavioral management
supportive employment
help managing stress and psychiatric symptoms including
management of medications
The provision of integrated services at one site or in home and
provision of an array of services for all family members was also
identified.
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Future studies need to address the specific
components of the treatments that appear to be
most helpful in working with this population.
Use of randomized treatment groups versus wait
list controls is needed to establish evidence based
treatments for working with this population.
Advocacy at the systems level needs to occur to
assist in the integration of adult and child services
to improve accessibility for providing family based
care.
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Future studies will have to examine the use of
identified treatment models for different age
groups from infancy through adolescents to
identify what components if any can be used
across age and developmental periods.
Perhaps future studies could identify similar
interventions and approaches that could be
used preventatively with parents experiencing
SMI versus waiting for child welfare
involvement.
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An important component that should be considered
is the addition of child education in understanding
the causes of parental illness to prevent the child
from mistakenly internalizing responsibility for a
parents’ illness and blaming themselves.
Consideration should be given to incorporating the
use of support groups for parents as well as children
and teens to improve needed support for these
families and provide psychoeducational materials.
The effectiveness of parenting support services for
fathers diagnosed with SMI needs further study as the
interventions discussed here were primarily
developed and used with mothers with SMI.
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