Descendenții părinților bolnavi psihici

Introduction

Public attention has been drawn to certain cases of children dying due to their mentally ill parents. Two children under the age of 15 die every week in Germany due to violence, physical abuse and neglect, and parental mental illness is a risk factor for such tragic events. The children of parents with mental illnesses (COPMI) are also frequently subjected to severe stress and limitations, which lead to a heightened risk of developing mental illness themselves⁽¹⁾.

According to the World Health Organization, one in eight people in the world lives with a mental illness. The prevalence of mental disorders is 13%, and 5.5% of adults suffer from a severe mental illness (SMI)⁽²⁾. One in five minor children are part of families in which a parent has a mental illness⁽⁶⁾. The percentage is 15-23%⁽¹⁵⁾. They present a significantly heightened risk of developing mental illnesses themselves⁽¹⁵⁾. Healthcare costs are five times higher for these children compared to other children⁽¹⁵⁾.

Children of parents suffering from SMI have a 30% risk of developing severe mental ilnesses themselves, while their risk of developing any other mental illness is 55%. The causes are both genetic and psychosocial – namely, traumatic childhood experiences⁽¹²⁾.

COPMI’s increased risk is also generated by the characteristics of their parents’ psychopathology in terms of symptom burden, comorbidities, personality disorders, and the severity and duration of their illness. These lead to a greater functional impairment, a poorer prognosis and to treatment complications⁽⁶⁾.

Besides the risk of mental illnesses, COPMI also run the risk of suicide. This risk is mainly generated by the mental illness (90%). Furthermore, the risk of suicide is also increased in children of parents with mental illnesses who have been exposed to suicidal thoughts and behaviors from their parents or to parental suicide⁽⁷⁾.

Environmental factors – traumatic childhood experiences

Mental illness affects the behavior of mentally ill parents towards their children, thus increasing the risk of children developing mental illnesses too, a risk that also comprises a genetic component⁽¹⁾.

Risk factors for children’s mental health can be identified at multiple levels. At parental level, they are represented by the specific psychiatric diagnosis, the severity and chronicity of the illness, by inadequate coping strategies and poor emotional availability. At family level, the risk factors are represented by domestic violence, lack of communication and social isolation. At the child level, we can find one’s temperament, cognitive and social skills and parentification. At psychosocial level, the risk factors are represented by insufficient social support and the lack of attachment figures outside the family. Risk factors multiply, they not just add up⁽¹⁵⁾.

The family risk factors that COPMI are often exposed to are represented by poverty, inadequate housing conditions, social marginalization, family discrimination, parental unemployment, loss of the parent who’s close to the child due to divorce, neglect and physical and sexual abuse⁽¹⁾, poor communication with the parent, the parent’s substance abuse disorder, and single-parent families⁽⁵⁾. The most difficult situation is when the parent’s mental illness, the child’s difficulties and a stressful family environment coexist simultaneously⁽⁵⁾.

Prenatal stage

The links between parental prenatal mental disorder and infant psychobiological functioning

The mother’s health during pregnancy can influence the child’s development. Previous studies have focused on the consequences of stress (traumatic), depression and anxiety in the prenatal period, leading to poor developmental outcomes in the cognitive, emotional area (reactivity) and in terms of physical health⁽⁹⁾.

The links of parental mental illness to infant psychobiological development

A child’s brain development is affected by the mother’s prenatal stress and by her health problems. The child’s amygdala microstructure and functional connectivity are affected by maternal depression and prenatal stress. The growth of the brain microstructures and the hippocampus is affected by maternal prenatal anxiety⁽⁹⁾.

Early childhood stage

Young children aged 1-2 years old have a higher risk of impaired cognitive development, behavioral problems, lower IQ scores during their late childhood, and they show increased rates of affective disorders during their teenage years, associated with parental depression⁽⁶⁾.

Maternal postpartum depression in the first five years affects the child by impairing cognitive development, alterations in physiological regulation, developmental delays, asthma, injuries, and an increased risk of mental illness later in life⁽¹⁷⁾.

Children under the age of 6 are often left untreated by the mental health services until their problems escalate, and they become vulnerable in their development. Their prognosis is the poorest⁽⁶⁾.

Late childhood stage

Subjective dimension

Children of parents with mental illnesses mention serious problems with their mental status. They face anxiety and confusion, because they cannot understand their parents’ problems, they feel guilty for having caused these problems themselves, they are not allowed to talk about their problems with other people, they are isolated and abandoned, and their academic and social progress is blocked because they must perform various tasks to please others and to survive. Those who paint their childhood in slightly brighter colors are those who have benefited from external support from their grandparents, their aunts, or from the healthy parent⁽²⁾.

Objective dimension

Children of parents with mental illnesses run the risk of developing the same illness as their parents or a wide range of mental illnesses⁽⁶⁾.

Children of parents with mental illnesses are two to four times more likely to develop a mental illness before the age of 18. This risk then increases to being 13 times higher, compared to children of parents not suffering from a mental illness⁽³⁾.

COPMI’s risk is higher when their parents have schizophrenia, obsessive-compulsive disorder, depression, substance abuse disorders, anxiety disorders, bipolar disorder, eating disorders, personality disorders, and suicide⁽⁶⁾.

The strongest risk factor for death by suicide in children of parents with mental illnesses remains the psychiatric illness, with a rate three times higher than that of those not suffering from psychiatric illnesses. This rate increases 39-fold in COPMI if they have a psychiatric hospitalization themselves. The risk of suicide has a 45% genetic transmission rate, but it is highly dependent on the presence of psychiatric illnesses. Environmental factors such as early adverse experiences like mistreatment, personal losses (death of a parent, separation), socioeconomic adversity and family dysfunction (parental mental illness, domestic violence, incarceration) contribute to the development of suicidal behaviors. Psychiatric illnesses cause alterations in the family functioning dynamics, affecting parents’ parenting capacity, thus leading to adverse experiences in children’s lives⁽⁷⁾.

Severe parental mental illnes has been associated, in COPMI, with behavioral problems, other mental health problems and suicidal and delinquent behavior during one’s adolescence, academic problems, and stress-related physical problems such as asthma or atopic disease, traumatic brain injury and malnutrition⁽¹³⁾.

Family factors associated with children’s problematic use of the internet

Children are frequent internet users, and they start at a very young age, often focusing addictively on games, social media applications, gambling, shopping, transactions, cybersex/pornography, entertainment and information websites. This addiction shows signs of impulsivity, addictive personality and psychosocial dysfunction. The problematic use of the internet leads to social withdrawal, low motivation, poor academic performance and loneliness, depression, anxiety, aggression, low self-esteem, and impairment of interpersonal relationships within the family and at school. Correlations have been made between children’s internet addictive behavior and parents’ mental health problems, such as depression, anxiety, addictive behaviors (alcoholism, smoking), internet addiction and parental phubbing⁽¹⁰⁾.

Adulthood stage

The feelings of shame, loneliness, fear, insecurity, lack of safety, sadness and anger remain present in the COPMI adult as well. Their role as a parent is marked by anxiety, because they are afraid that their own child could inherit the parent’s illness. They also face problems in their relationships with their peers, family, friends and parents. They do not reveal their parent’s illness to others due to stigma. Their physical health is often affected by somatic symptoms such as migraines, sleep disorders, chronic inflammatory bowel disease and facial paralysis. The COPMI adult does not talk about abuse and psychiatric problems as a priority. They face a 70% risk of depressive and anxiety disorders and other types of psychopathologies, such as schizophrenia, substance abuse and suicidality, and somatic symptom disorder. Besides, their physical health is also affected by medical problems and mortality, starting around the middle age. At the age of 35, they are twice as likely to have any medical disorder compared to the reference group⁽³⁾.

Suicide is the leading cause of death for individuals aged 20-34 in the UK. The risk of suicide is most tightly associated with mental illness (90%). Suicidal thoughts and behaviors and suicide attempts are higher in those who have been exposed to paternal suicidal thoughts and behaviors and to parental suicide. The causes of this suicide risk transmission are genetic, but they are also represented by one’s exposure to adverse childhood experiences, including parental mental illness, especially major depression, panic disorder, generalized anxiety disorder, substance addiction and antisocial behavior (illegal behavior, detention or incarceration)⁽⁷⁾.

The impact of parental suicidal behavior is reflec­ted in the mood, physical health, academic and social outcomes, and suicidal behavior of the COPMI adult. Besides, they may also have a higher risk of developing substance abuse disorders, mainly related to stimulants, sedatives, tranquilizers and opioids. COPMI adults who have witnessed fighting at home develop addictions related to illegal drugs (cannabis, cocaine and alcohol)⁽⁸⁾.

Resilience

Resilience is one’s capacity to adapt appropriately, despite exposure to adverse or stressful life events⁽¹²⁾.

Resilience in children of parents with mental illnesses is associated with coping strategies, protective factors, and the absence of symptoms or risky behavior in the face of exposure to adverse events. Resilience resources are divided into three level categories: individual, family-related, and outside the family⁽¹¹⁾.

Coping strategies refer to emotional awareness, problem-solving skills, help-seeking, and developing interpersonal relationships to cope with adverse situations⁽¹³⁾.

External protective factors can be found in the child’s environment at family level (positive parenting and a stimulating environment at home), in the community (supportive school system), and at cultural level (gender equality and economic health)⁽¹²⁾.

Children of parents with mental illnesses have described a process of detaching from the ill parent, understanding one’s own needs, and reducing the tendency to please others to develop themselves⁽²⁾.

However, it should not be assumed that, because they are resilient, COPMI are not vulnerable, and they do not require support. Adverse childhood experiences lead to an increased risk of developing physical or mental health problems during adulthood⁽⁴⁾.

Interventions

In most European health policies, this segment of children of parents with mental illnesses is almost completely neglected, although it is characterized by an increased disability and a high risk of transgenerational transmission of their psychopathology⁽¹⁴⁾.

To support these children, positive parenting programs have been developed for vulnerable people, programs for emotional regulation and for reducing the risk of behavioral disorders. These have provided long-term results concerning the well-being of the child, the parent and the family⁽¹³⁾.

Over the past few years, psychological intervention programs have been implemented in some countries to support COPMI by developing protective factors within these families. These interventions focus on parent-child interactions and on the physical, social, emotional and intellectual needs of the children, because children of parents with mental illnesses need social support. The risk of developing a mental illness was 50% higher in COPMI who did notbenefit from any interventions⁽¹³⁾.

To prevent COPMI’s negative sliding towards mental illnesses, multiple programs have been developed over the last decades to support families with mentally ill parents. These programs were designed for the child (peer support groups, psychoeducation), the parent (parent groups, couple therapy, parenting skills groups), and the family (counseling, family therapy, family assistance)⁽¹⁵⁾.

It has been noted that the risk of developing a men­tal illness decreases by 40% with family-focused in­ter­ven­tions⁽⁶⁾.

The psychoeducation of COPMI about their parent’s illness has been a key element in these programs. Cognitive and behavioral approaches have also been common in these interventions to increase parenting skills and the child’s resilience⁽¹⁵⁾.

Other programs

1. Family Talk has been the first family-oriented preventive program, and it has been implemented in many countries⁽¹⁴⁾.

2. Group programs based on cognitive-behavioral interventions and treatment coordination have been developed as alternatives to the family-oriented approaches⁽¹⁴⁾.

3. Web-based, parent-focused programs⁽¹⁴⁾.

4. Psychosocial education for children⁽¹⁴⁾.

5. Additional programs such as The Think Family-Whole Family Program or the CAMILLE training program, allowing professionals to be trained, to assist families, as the children grow and families go through difficult times, due to the parent’s illness⁽¹⁶⁾.

6. Multi-family programs or group components focused on increasing the social support networks of families. These families experience these interventions in a positive manner, by sharing their experiences, meeting other families, and establishing social connections to reduce social isolation and marginalization⁽¹⁶⁾.

7. The Building Emotional Awareness and Mental Health (BEAM) Program has been developed for an early intervention on mothers with postpartum depression, to tackle the long-term consequences of depression during the child’s preschool years. The program consists of parenting psychoeducation, peer support forums, and weekly web-based health sessions. The results of this program are represented by a reduction of the maternal depressive symptoms and of parenting stress, as well as the reducing of the internalizing and externalizing symptoms in the child⁽¹⁷⁾.

8. A psychiatric treatment for the parent or the child can help the child develop normally. A children’s and teenagers’ psychiatrist can help the family with positive elements related to the environment and the child’s natural strengths to minimize the effects of the parent’s mental illness on the child⁽⁵⁾. Very often, the child is neglected by mental health services, which focus on the sick parent⁽⁵⁾.

9. In the Norwegian Policies, an amendment was stipulated in 2010, requiring adult mental health services to identify and respond to the needs of children of parents with mental illnesses⁽⁶⁾.

10. Parenting classes for parents suffering from mental illnesses, meant to improve their parenting skills. An example of a web parenting program is provided: Parentingwell.org. It includes an online community, tools, and other resources. For parenting skills, you can also visit the Parenting section of the Temple University Collaborative on Community Inclusion website⁽⁵⁾.

11. Child protection services are involved in families where the child does not have access to any caregivers other than the mentally ill parent. Mental health service staff have been seen to be reluctant to refer families to the child protection services⁽⁶⁾.

12. Living arrangements for the child. The child cannotlive with the sick parent if the parent has a serious mental illness, if the parent has an addiction disorder, and if the sick parent is the father⁽⁶⁾.

13. Losing children’s custody. This often happens when the parent has a serious mental illness due to the stress that puts on the children, their poor parenting skills, the economic problems, but also due to the attitude of the mental health professionals, social workers and the child protection system. The extra resources needed by the family may not be available and, thus, the mentally ill parents may lose custody. The severity of the illness characterized by disorientation and the adverse effects of psychotropic drugs, as well as the absence of other adults in the household are reasons for losing custody. Twenty-five percent of the social workers’ cases mention children’s abuse and neglect. A parent who has lost custody goes through traumatic times, which aggravates his/her illness and reduces his/her prospects of regaining custody. As a result of these measures, mentally ill parents do not seek help for their illness⁽⁵⁾.

14. Helping families stay together. The lack of specialized services for families and the stigma associated with mental illnesses make it difficult for families to access help to stay together⁽⁵⁾.

Conclusions

The study results reveal the need for professionals to become aware of the long-term effects of adverse experiences of children of parents with mental illnesses, so that their interventions would address the children’s needs at various development stages⁽²⁾. Professionals, particularly those working in the field of mental healthcare, need to assess the adverse experiences lived by their adult patients’ children. During childhood, one needs to have his/her existential needs fulfilled, as well as support for any potential educational and social challenges. It is well known that this population group of children of parents with mental illnesses do not seek help directly⁽²⁾.

Suicide is a major problem and, therefore, early identification of children at high risk is crucial for the treatment of mental illnesses and for the prevention of suicide⁽⁷⁾. Besides, COPMI who are exposed to parental suicide attempts are also prone to substance use disorders, involving mainly stimulants, tranquilizers, sedatives and opioids⁽⁸⁾.

During their childhood, children of parents with mental illnesses often develop coping mechanisms for survival, but on the long term, including when they reach adulthood, they face mental and physical health problems, care burdens, relationship problems, loneliness, lack of confidence, and reluctance to seeking and accepting help⁽²⁾.

A sustained effort is needed to identify those children of parents with mental illnesses who are exposed to a higher risk of adverse mental health outcomes in adulthood. A multigenerational approach is often necessary to help an adult COPMI integrate into his family environment, with support from psychoeducation, social skills training, and insight into secure attachment⁽³⁾.

During their infancy, a parental psychopathology leads to a suboptimal environment for the children’s development through a negative insecure pattern. The descendants may generalize this pattern, thus choosing mentors, teachers and romantic partners who behave the same way as the parent affected by the psychopathology⁽⁹⁾. It is important to educate parents and expectant parents about the fact that mental health problems in the perinatal period are common, and they can be overcome with professional help. Parents are reluctant to seeking help because of the stigma surrounding this issue and the fear of losing the custody of their children⁽⁹⁾.

The BEAM program has demonstrated its effectiveness during this infancy stage by its recruitment rates, its attention, and the participants’ reports regarding its usefulness⁽¹⁷⁾.

Whole-family interventions are the most effective ones, and their central component focuses on family psychoeducation, to improve parenting, which is a protective factor for children⁽¹⁶⁾. Studies reveal the need to continue whole-family interventions for a longer period, through booster sessions and support from professionals during the life transitions that families go through⁽¹⁶⁾.

Educational and political implications for future research

A clear definition of serious mental illness is needed at international level to facilitate the development of national policies and to create an international research framework⁽²⁾. It is important for these policies to support institutions in providing mental health services to this demographic group of COPMI. Besides, the educational curricula should also include measures for the needs of this population segment⁽²⁾.

Children of parents with mental illnesses aged 0-5 years old need interventions because they are the most invisible and the most vulnerable, and there are very few services available to them⁽⁶⁾. Almost one in three children lives alone with a mentally ill parent, and they do not have access to another adult at home to compensate for this lack of normal functionality. To reduce the risk of COPMI developing social problems and mental health disorders, a close cooperation is needed between mental health services and social services, to reduce the intergenerational transmission of psychiatric disorders⁽⁶⁾.

The study’s observations regarding children’s proble­matic use of internet suggest that more prospective studies are needed, with both parents and children, to understand the causality and to develop effective interventions for children⁽¹⁰⁾.

Preemptive interventions are necessary, as demonstrated by the results of previous studies; therefore, a future randomized-control trial is needed to implement a selective prevention program in our country⁽¹³⁾. This study could focus on improving support and parenting among mentally ill parents, improving COMPI’s well-being, setting out the preemptive interventions, facilitating the mental dimension of a healthy childhood, and establishing the recommendations needed for an integrated treatment of patients suffering from mental disorders and their children, with specific trainings for mental health clinicians⁽¹⁴⁾.

 

Autor corespondent: Raluca Pretorian E-mail: pretorianraluca@yahoo.com

 

 

 

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.