Dear Editor,
Extensive research has shown that parental mental illness is associated with an increased risk of psychological and developmental problems in their offspring. In families where both parents have a mental illness, there is at least a 30–50% chance of the child becoming seriously mentally ill (Bowlby, Reference Bowlby1969). The relationship between parental mental illness and their offspring is complex and involves a number of mechanisms including environmental (emotional unavailability, poor living conditions, overcrowding, marital conflict) and genetic factors. Conversely, the demands of a child’s psychiatric disorder may cause increased parental stress and lead to the development of mental health difficulties in parents.
It is crucial to be able to recognise parental mental illness, including the presence of parental personality disorders, in order to understand a child’s vulnerability and risk factors. Parental responses lead to the development of patterns of attachment that in turn lead to ‘internal working models’, which will guide the individual’s feelings, thoughts and expectations in later relationships (Brent et al. Reference Brent, Kolko, Birmaher, Baugher, Bridge, Roth and Holder1998). A parent with an emotional vulnerability may not have the capacity to take a child-centred perspective and may struggle to meet his/her child’s needs in a warm and consistent manner. Research has shown that the offspring of depressed mothers are at an increased risk for the development of insecure attachment relationships (Cummings & Cicchetti, Reference Cummings and Cicchetti1990; Gunlicks & Weissman, Reference Gunlicks and Weissman2008) and they are more at risk of developing psychiatric illness, cognitive and medical difficulties (Murray, Reference Murray1992). Moreover, research suggests that the presence of psychopathology in parents may have an adverse impact on a child’s progress, attendance and response to treatment. Brent et al. (Reference Brent, Kolko, Birmaher, Baugher, Bridge, Roth and Holder1998) found that depressed children whose mothers had depressive symptoms were unlikely to respond to treatment (Pilowsky et al. Reference Pilowsky, Wickramaratne, Talati, Tang, Hughes, Garber, Malloy, King, Cerda, Sood, Alpert, Trivedi, Fava, Rush, Wisniewski and Weissman2008). A more recent study has shown that an improvement in maternal depression is associated with a reduction in the child’s diagnosis and symptoms (Rubovits, Reference Rubovits1996). This is true not only for depression but also for attention deficit hyperactivity disorder (ADHD). The authors have had experience of a number of cases of children with mental health problems, only being able to improve when the parental ADHD was considered, recognised, and accepted as a possibility and treated.
Parental insight into the presence of his/her own mental health problem is a significant issue. Some parents can become very dismissive, insulted or guarded if their own mental health is explored. Skilful diplomacy is therefore crucial to minimise parental defensiveness, disengagement and to maintain a therapeutic alliance. A considerable amount of psychoeducation and support may be required for parental insight to dawn and for their agreement to engage in treatment. However, this essential step can often be the turning point for the child and his/her management, progress and outcome.
We attempted to carry out a pilot study with the aim of evaluating the prevalence of psychopathology in parents of children attending our Child and Adolescent Mental Health Service (CAMHS). We sent 50 letters to parents of children who had recently been assessed at our clinic over a 3-month period. Letters provided parents with information about the study and an invitation to attend a 40-minute interview using three screening tools. It was made explicit that their involvement would not have any influence on their child’s management and that their GP would be sent the results of their assessment, with further follow-up arranged, if indicated.
We encountered a number of recruitment barriers. Fifteen parents had contacted the clinic indicating that they would be interested in taking part; however, they were unable to attend owing to work commitments or lack of childcare. Only two parents were able to participate (male=1; female=1). Each parent had indicated that he/she had been previously treated for a depressive illness following marital separation. During parental treatment the children were referred to CAMHS with emotional problems. Neither participant fulfilled criteria for an Axis 1 psychiatric diagnosis. Both participants did not fulfil the criteria for any axis 1 psychiatric diagnosis at the time of the assessment.
Our poor recruitment participation rate highlights a number of challenging issues for this type of research study. Parents may feel disconcerted or apprehensive about undergoing a formal psychiatric interview. Those with an existing or pre-existing psychiatric disorder may not be willing to participate as they may feel stigmatised or fearful of the consequences to their children. Time commitments are another important issue that may suggest the need to use alternative methods. The risk of response bias is an important issue to consider. Parents may perceive that they are to be blamed for their child’s problem, which may influence their responses to a screening questionnaire.
The authors propose some suggestions, which would benefit further research. One approach might be that this research would be best conducted in the parents’ home. This strategy might yield greater cooperation, however, time constraints did not permit this. Another proposal is to conduct a brief mental health screening of all parents whose child is referred to CAMHS, as a standard procedure. Those parents who are interested, could then be given information on where and how they could access psychological or psychiatric help for themselves. Ideally, this psychiatric help could be provided by an adult mental health professional in CAMHS premises.
As clinicians working with children, identification and treatment of parents’ mental health needs should lead to an overall improved outcome in children and their families. To identify those families most in need, further research needs to be done on this area in order to optimise our clinical practice and service provision.
