Increasing Resilience in Children of Parents with Severe Mental Illness

1. Increasing Resilience in Children of Parents with Severe Mental Illness By: Jennifer Richardson, MA

2. Goals of Workshop • 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.

3. Mental Health Stigma-where we were and where we are • 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.

4. Parenting with Severe Mental Illness • 2/3of 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.

5. Parents with Severe Mental Illness • 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).

6. Impact of SMI on parenting stress • 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).

7. Impact of SMI on parenting • 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

8. Risk of Child Custody Loss • Families with parental mental illness are considered to be at increasedrisk 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.

9. Risk of Child Custody Loss • 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).

10. Impact of SMI on offspring • 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).

11. Impact of SMI on offspring • 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 self-regulatory 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).

12. Child Development and Parent SMI • 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. • Some evidence suggests early exposure to maternal depression, is more deleterious than later exposure. • an older child is thought to be less vulnerable to adverse influences as a result of having more mature behavioral systems. • 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)

13. Nurture vs Nature • 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).

14. Suicide Risk in Offspring • 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: • offspring of parents diagnosed with MDD- increased risk starting in childhood • offspring of parents with bipolar disorder- significant increase in risk for and severity of suicide thoughts and behaviors in young adulthood but not in childhood.

15. Parent Diagnosis and Differential Effects • According to Mowbrayet 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.

16. Parent Diagnosis and Differential Effects • 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).

17. Risk & Resiliency in Offspring of Parents with SMI • Qualitative studies examining risk and resiliency in children with a SMI parent found the following traits more common in children who struggled with adjustment: • children who expressed self-blame, • took undue responsibility for the parent’s illness and/or problems, • and had little understanding of the nature of the parents illness (Cooklin, 2008).

18. Risk & Resiliency in Offspring of Parents with SMI • 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

19. Risk & Resiliency in Offspring of Parents with SMI • 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).

20. Risk & Resiliency in Mothers with SMI and their Offspring • 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).

21. Important Considerations • 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.

22. Review of Family Interventions • 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, family-driven 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.

23. Review of Family Interventions • 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: • recognition of the common occurrence of adults with SMI having and raising children. • Belief that with adequate supports parents with SMI can parent effectively. • Central goal of preserving integrity of the family, prevention of disruption and custody loss.

24. Review of Family Interventions • important components thought to impact effectiveness of the interventions include: • parent education aspect of the program • coordination of care across multiple providers facilitated by a case manager • access to flexible funding for use in emergencies and to assist in accessing necessities • therapeutic nurseries provided with a focus on child development. • importance of inter-agency collaboration and need for integrated services across adult and child service sectors (Hindenet al., 2005).

25. Review of Family Interventions • 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. • ICP is family centered, comprehensive, strengths-based, emotionally supportive and nonjudgmental. • Role of the case manager in ICP is to provide coordination of multiple providers, improved comprehensibility and accessibility. • Case managers are available for 24 hour problem solving support. • 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).

26. Review of Family Interventions • 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: • engagement in treatment • assessment • linkage to environmental supports • parenting skills training using a modeling and coaching approach. • coordination of services for both adult and child to improve communication.

27. Review of Family Interventions • 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.

28. Future Directions • 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.

29. Future Directions • 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.

30. Future Directions • 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 psychoeducationalmaterials. • 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.

31. Questions???

32. References Beardslee, W., & Podorefsky, D. (1988). Resilient adolescents whose parents have serious affective and other psychiatric disorders: Importance of self-understanding and relationships. The American Journal of Psychiatry, 145, 63-69. Brunette, M.F., Richardson, F., White, L., Bemis, G., Eelkema, R. (2004). Integrated family treatment for parents with severe psychiatric disabilities. Psychiatric Rehabilitation Journal, 28, 177-180. doi: 10.2975/28.2004.177.180 Cooklin, A. (2008). Children as carers of parents with mental illness. Psychiatry, 8, 17-20. Craig, E. (2003). Parenting programs for women with mental illness who have young children: a review. Australian and New Zealand Journal of Psychiatry, 38, 923-928. Goodman, S., & Gotlib, I. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106, 458-490. Hanrahan, P., McCoy, M., Cloninger, L., Dincin, J., Zeiter, M., Simpatico, et al. (2005). The mothers’ project for homeless mothers with mental illness and their children: A pilot study. Psychiatric Rehabilitation Journal, 28, 292-294. doi: 10.2975/28.2005.291.294 Hinden, B., Biebel, K., Nicholson, J., Henry, A., & Katz-Leavy, J. (2006). A survey of programs for parents with mental illness and their families: Identifying common elements to build the evidence base. Journal of Behavioral Health Services and Research, 33, 21-38.doi: 10.1007/s11414-005-9007-x Hinden, B., Biebel, K., Nicholson, J., & Mehnert, L. (2005). The invisible children’s project: Key ingredients of an intervention for parents with mental illness. The Journal of Behavioral Health Services and Research, 32, 393-408.

33. References Lapalme, M., Hodgins, S., & LaRoche, C. (1997). Children of parents with bipolar disorder: A meta-analysis of risk of mental disorders. Canadian Journal of Psychiatry, 42, 623-631. Kahng, S., Oyserman, D., Bybee, D., & Mowbray, C. (2008). Mothers with serious mental illness: When symptoms decline does parenting improve? Journal of Family Psychology, 22, 162-166. doi: 10.1037/0893-3200.22.1.162 Katz, S., Hammen, C., & Brennan, P. (2013). Maternal depression and the intergenerational transmission of relational impairment. Journal of Family Psychology, 27, 86-95. doi: 10.1037/a0031411 Klimes-Dougan, B., Long, J., Lee, C., Ronsaville, D., Gold, P., & Martinez, P.E. (2010). Continuity and cascade in offspring of bipolar parents: A longitudinal study of externalizing, internalizing, and thought problems. Development and Psychopathology, 22, 849-866. doi: 10.1017/S0954579410000507 Klimes-Dougan, B., & Martinez, P. (2008). Suicidal risk in young adult offspring of mothers with bipolar or major depressive disorder: A longitudinal family risk study. Journal of Clinical Psychology, 64, 531-540. doi: 10.1002/jclp.20468 Mowbray, C., Bybee, D., Hollingsworth, L., Goodkind, S., & Oyserman, D. (2005). Living arrangements and social support: Effects on the well-being of mothers with mental illness. Social Work Research, 29, 41-55. doi: 10.1093/swr/29.1.41 Mowbray, C., Bybee, D., Oyserman, D., MacFarlane, P., & Bowersox, N. (2006). Psychosocial outcomes for adult children of parents with severe mental illness: Demographic and clinical history predictors. Health and Social Work, 31, 99-108. doi: 10.1093/hsw/31.2.99

34. References Nicholson, J., Albert, K., Gershenson, B., Williams, V., & Biebel, K. (2009). Family options for parents with mental illnesses: A developmental, mixed methods pilot study. Psychiatric Rehabilitation Journal, 33, 106- 114. doi: 10.2975/33.2.2009.106.114 Nicholson, J., & Henry, A. (2003). Achieving the goal of evidence-based psychiatric rehabilitation. Psychiatric Rehabilitation Journal, 27, 122- 130. doi: 10.2975/27.2003.122.130 Nicholson, J., Sweeney, E., & Geller, J. (1998). Mothers with mental illness. The competing demands of parenting and living with mental illness. Psychiatric Services, 49, 635-642. Oyserman, D., Bybee, D., Mowbray, C., Hart-Johnson, T. (2005). When mothers have serious mental health problems: Parenting as a proximal mediator. Journal of Adolescence, 28, 443-463. doi:10.1016/j.adolescence.2004.11.004 Oyserman, D., Mowbray, C., Meares, P., Firminger, K.B. (2000). Parenting among mothers with a serious mental illness. American Journal of Orthopsychiatry, 70, 296-315. doi: 10.1037/h0087733 Seeman, M. (2012). Antipsychotic-induced somnolence in mothers with schizophrenia. Psychiatry Quaterly, 83, 83-89. doi: 10.1007/s11126- 011-9185-z