Sept/Oct 2007

Reaching Out to Children of Parents With Mental Illness
By Michelle D. Sherman, PhD
Social Work Today
Vol. 7 No. 5 P. 26

Social workers have great opportunities to support children of parents with mental illness. Get 10 tips on how to help.

“Sometimes I [June, aged 9] would come home and she [my mom] would say, ‘Who are you? Get out of my house,’ and she’d threaten to call the cops. She had no idea who I was. I was always afraid that she was going to call the police, and they would come and see that she’s insane, and they would take me away from my sister.”

— Excerpt from Daughters of Madness: Growing Up and Older with a Mentally Ill Mother by Susan Nathiel

“And at home she [Mary Wells, a mother of two girls] went to pieces. She scarcely got up to make the girls breakfast or to see them off to school in the morning, and she was often still lying in bed in the back room, drinking gin and smoking, when they came home in the afternoon. They would come to her room and stand in the doorway and look at her. Sometimes they would lie down on the bed beside her and go to sleep in that place that used to be so pleasant and comfortable. More often now the two sisters would fight with each other when they were home and she would call them to stop, but other times she would simply get up and shut the door and light a cigarette and lie down again.”

— Excerpt from Eventide by Kent Hanuf

Scope of the Issue
More than five million children in the United States have a parent with a serious mental illness (SMI) such as schizophrenia, bipolar disorder, or major depression. Contrary to popular belief, adults with an SMI or posttraumatic stress disorder (PTSD) are just as likely to be parents. In fact, 68% of women with an SMI are mothers and 57% of men with an SMI are fathers; further, 73% of women with PTSD and 68% of men with PTSD are parents (Nicholson, Biebel, Katz-Leavy, & Williams, 2004).

Although each child’s experience is unique, living with a parent with an SMI or PTSD can be embarrassing, confusing, lonely, and scary. To date, these children have received little attention. Social workers—whether they specialize in treating adults or youths—have a tremendous opportunity to see and hear these children.

Effects of Parental Mental Illness on Youths
Social workers know that when one person in the family experiences difficulties, everyone is affected. Everyday family life can become confusing and frightening. Young family members often take on adult responsibilities and experience uncertainty, anger, shame, sadness, and fear, asking “What is this all about? Why is it happening to me? How can I make my parent better? Will I be like my parent some day? What do I tell my friends?”

Sometimes, parents living with an SMI “act out” in confusing, upsetting ways, such as during times of active psychosis (as described in June’s story above). Parents with difficulty dealing with strong feelings may explode in anger, scaring the child. Parents living with mood disorders may struggle with suicidal thinking and behavior, which can be very distressing. When parents act out in these ways, children may experience their parents as hostile, scary, out of control, and unpredictable. In turn, the children feel anxious, ashamed, sad, and angry.

Parents (and the other parent/family members in the home) often become preoccupied with managing the illness, and much of the family’s attention is directed to that person. Furthermore, the parent living with the SMI may detach (intentionally or unintentionally) from the child. Parental hospitalization and other separations from the parent (sometimes including the child living with other family members) can disrupt the parent-child bond. Particularly with PTSD, many parents develop emotional numbness, which also interferes with the development of close relationships. Detachment, physical separation, and emotional numbing can directly impact the parent’s ability to engage the child in everyday activities. Confused by the parental unavailability, children often feel uncared for, unloved, left out, and lonely. Children may also blame themselves for the change in their parent.

It is important to note that children growing up with parents with an SMI can also develop valuable personal strengths. For example, adults reflecting on their upbringing in this family situation have described enhanced awareness of their own compassion, sensitivity, resourcefulness, strength, and independence (Marsh, Appleby, Dickens, Owens, & Young, 1993).

Research on Child Outcomes
Young people growing up with parents dealing with emotional problems are at greater risk of having behavioral/emotional problems themselves due to genetic factors and harmful psychosocial experiences. In fact, the rates of child psychiatric diagnosis among offspring range from 30% to 50% (vs. 20% in general population) (Nicholson et al, 2004). More specifically, these youths are at considerable risk for behavioral problems (Rutter & Quinton, 1984), major depression (Beardslee, Gladstone, Wright, & Cooper, 1998), and anxiety disorders (Nomura, Wickramaratne, Warner, Mufson, & Weissman, 2002). They are more likely to experience developmental delays, poorer school performance, and problems with peers (Sameroff & Seifer, 1983; Weintraub & Neal, 1984). Importantly, longitudinal research of these children has documented that these outcomes often persist into adulthood, even at 10-year follow up (Nomura et al, 2002).

In general, child outcomes relate not only to the parent’s illness but to a wide range of other factors, including the child’s coping skills, the family’s socioeconomic status, the level and quality of social support, and access to treatment (Nicholson et al, 2005). As large numbers of parents with an SMI lose custody of their children (some research estimates rates of 70% to 80%, e.g., Joseph, Joshi, Lewin, & Abrams, 1999), the changes in living arrangements and family configurations can also affect child functioning.

Preliminary research has found some positive outcomes for prevention programs for children of parents living with an SMI (e.g., Beardslee et al, 2003), but more research is needed. Programs such as the Mental Health America’s Invisible Children’s Project (Hinden, Biebel, Nicholson, & Mehnert, 2002), which provides home-based, family-centered case management for parental mental illness, are promising, but little dissemination has occurred.

What Do These Young People Need?
Although some self-help books are available for adults whose loved one has an SMI, few written resources are available for youths. A few picture books have been written for young children, but few resources exist for elementary, middle, and high school youths. Two exceptions include Wishing Wellness: A Workbook for Children of Parents With Mental Illness (Clarke, 2006) and I’m Not Alone: A Teen’s Guide to Living With a Parent Who Has a Mental Illness (Sherman & Sherman, 2007).

The current arrangement of most mental healthcare separates treatment of adults and children. Youth and adult providers often do not even know each other. The facilities may be geographically distant from one another. Funding sources and chains are often distinct. Collaboration of treatment for a family is rare. Sadly, this arrangement creates a gap in care and perpetuates the problem of minimal attention to the parenting/children.

Social workers, with skills in navigating complex systems, coordinating care among a wide range of providers, and empowering the underserved, are in a unique position to address this problem. Workers specializing in treating adults (such as in adult inpatient psychiatric units, Veterans Administration hospitals, day treatment programs) are challenged to open the dialogue with all their clients about this topic. Asking about the challenges faced in parenting, the impact of the illness on their children, and what community support is available for the children can be extremely helpful.

In addition, social workers primarily treating children are encouraged to assess this facet of the child’s experience. Remembering that one in five families has a member living with an SMI, many children who social workers serve have parents dealing with these issues. Assessing the impact of the parent’s illness on the youth and asking about other adults who can help when the parent is unable can be useful.

Children of parents with an SMI need information, support, and hope. Social workers can see, hear, and support these young people in many important ways. The following are 10 concrete things that these youths need:

1. Reassurance that they’re not alone.
The experience of an SMI in the family can be lonely and confusing. Regardless of the illness, all young people need to be reminded that they are not alone. Social workers can help to minimize this sense of isolation by establishing support groups for teens and families dealing with an SMI. The opportunity to talk to other people who face similar situations can be comforting and healing.

2. Honest acknowledgement of the parent’s difficulties.
Some families avoid talking about the illness with the hope that this approach will be less stressful for the child. However, ignoring the proverbial “elephant in the room” creates even more problems. Even if the family and adults are trying to protect the children, young people may feel quite resentful, even years later. Therefore, it’s important to talk openly about various struggles that families face instead of perpetuating the secrecy and shame often surrounding mental illness.

3. Information about the illness.
People (kids especially) fear what they do not understand. Kids need answers to questions like: “What is going on? Why is this happening to me? How can I make my parent better? Will I be like my parent some day?” Tara Elgin Halley has written about her experience of growing up with a mother dealing with an SMI: “I wanted to love her (my mom)—I did love her—but I was tired of carrying around this burden. I just wanted life to be normal … To imagine my mother as my future was almost more than I could bear” (Nathiel, 2007, p. 91).

Connecting with community resources (such as the National Alliance on Mental Illness or the Depression and Bipolar Support Alliance) can increase your awareness of support available for these families.

You may host a family day or children’s program in which you provide psychoeducation. You can talk about famous people who have mental illness. May (National Mental Health Month) and October (containing Mental Health Awareness Week) are especially good times to highlight these topics. Talking openly about these issues helps reduce the stigma and encourages young people to confide in you.

4. To be told that they are not to blame.
Young people often blame themselves when problems arise in a family. It’s reassuring for children to be told they didn’t do anything wrong. Sending this message clearly and consistently can relieve considerable guilt and shame among teens.

5. To know that the parent loves them.
Reminding young people that their parent cares about them can be comforting. Sometimes, parents behave in rejecting ways that can be confusing and hurtful to children, or parents are so consumed with their own problems they’re unavailable for their kids. Explaining why parents act in confusing ways can help kids avoid taking the behavior personally. Further, encouraging children to consider that their parents are probably “doing the best they can” under the circumstances can be useful.

6. To be able to be kids.
Due to the family’s preoccupation with the parent, some youths are given excessive responsibilities such as childcare for younger siblings, household chores, and even managing the parent’s behavior and medications. It’s important for kids to be able to get away from the heavy burdens at home and just have fun. For example, one teenage girl whose father has bipolar disorder said: “Forever I wanted to take on the burdens of my family … I finally learned I didn’t have to do that. The faster you can figure that out, the better” (Sherman & Sherman, 2007, p. 91).

7. Support in knowing how to deal with stigma and their friends.
Sadly, stigma continues to surround people living with mental illness. Often, people forget that this stigma extends to the person’s family as well, so the young people in the family often feel embarrassed and ashamed. For example, family and friends usually bring casseroles, send cards, and visit when someone has a physical health problem such as undergoing surgery; however, emotional problems typically evoke different responses from the community. Family and friends may make hurtful comments or may avoid the family, which further compounds the pain and grief for the youth.

Social workers can empower teens by providing education and support in dealing with friends. For example, social workers can role-play with teens about how to respond to friends’ unkind comments. Social workers can help teenagers weigh the pros and cons of talking about family problems with trustworthy friends.

8. Safe people to talk to.
These young people need support from healthy adults and teens in their extended family, community, school, and church. Research has clearly found that young people growing up in challenging family situations have better outcomes if they have one positive adult in their lives to support them along the way.

A social worker can be this important person. You can be emotionally present and supportive to these youths and their families, providing a confidential, accepting environment. You can listen to and validate teens’ emotional pain without judging them or rushing in to give advice. Making time to be available and providing a supportive, listening ear can be invaluable.

9. Empowerment.
Although young people cannot fix their parent, they often want to be helpful. Social workers can brainstorm with teens about small, specific ways they can support their parent, such as by playing cards together, sending a kind e-mail, or cleaning his/her room without being asked.

10. Hope.
It’s important for kids to know that situations probably won’t always feel as tough, and many effective treatments are available for their parent. Recovery from serious mental illness is possible.

Despite the challenges involved in dealing with mental illness, facing difficulties can bring families closer together. Both parents and children may discover strengths, resilience, and courage in themselves and each other that never would have surfaced otherwise. Families can grow by communicating openly and supporting each other so that they can navigate future difficulties more effectively.

— Michelle D. Sherman, PhD, is a licensed clinical psychologist, the director of the Family Mental Health Program at the Oklahoma City Veterans Affairs Medical Center, and a clinical associate professor in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center. She cowrote two books for teens, Finding My Way: A Teen’s Guide to Living with a Parent Who Has Experienced Trauma and I’m Not Alone: A Teen’s Guide to Living with a Parent Who Has a Mental Illness (www.seedsofhopebooks.com).

References

Beardslee, W.R., Gladstone, T.R., Wright, E.J., & Cooper, A.B. (2003). A family-based approach to the prevention of depressive symptoms in children at risk: Evidence of parental and child change. Pediatrics, 112(2), e119-131.

Beardslee, W.R., Versage, E.M., & Gladstone, T.R. (1998). Children of affectively ill parents: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry, 37(11), 1134-1141.

Clarke, L.A. (2006). Wishing Wellness: A Workbook for Children of Parents with Mental Illness. New York: Magination Press.

Hinden, B., Biebel, K., Nicholson, J. & Mehnert, L. (2002). The Invisible Children’s Project: A Family-Centered Intervention for Parents with Mental Illness. Retrieved June 24, 2007 from http://www1.nmha.org/children/invisibleChildrensProject.pdf

Joseph, J.G., Joshi, S.V., Lewin, A.B. & Abrams, M. (1999). Characteristics and perceived needs of mothers with serious mental illness. Psychiatr Serv, 50(10), 1357-1359.

Marsh, D.T., Appleby, N.F., Dickens, R.M., Owens, M. & Young, N.O. (1993). Anguished voices: Impact of mental illness on siblings and children. Innovations & Research, 2(2), 25-33.

Nathiel, S. (2007). Daughters of Madness: Growing Up and Older with a Mentally Ill Mother. Westport, CT: Praeger.

Nicholson, J., Biebel, K., Katz-Leavy, J., & Williams, V.F. (2004) The prevalence of parenthood in adults with mental illness: Implications for state and federal policymakers, programs, and providers. In: Center for Mental Health Services. “Mental Health, United States, 2002.” Manderscheid, R.W., & Henderson, M.J., eds. DHHS Pub No. (SMA) 3938. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 120-137.

Nomura, Y., Wickramaratne, P.J., Warner, V., Mufson, L., & Weissman, M.M. (2002). Family discord, parental depression, and psychopathology in offspring: Ten-year follow-up. J Am Acad Child Adolesc Psychiatry, 41(4), 402-409.

Rutter, M., & Quinton D. (1984). Parental psychiatric disorder: Effects on children. Psychol Med, 14(4), 853–880.
Sameroff, A.J. & Seifer, R. (1983). Familial risk and child competence. Child Dev, 54(5), 1254-1268.

Sherman, M.D., & Sherman, D.M. (2007). I’m Not Alone: A Teen’s Guide to Living with a Parent Who Has a Mental Illness. Edina, MN: Beavers Pond Press.

Weintraub, S. & Neal, J. M. (1984). Social behavior of children at risk for schizophrenia. In N.F. Watt. E. J. Anthony, L. C. Wynne and J. E. Rolf (Eds.), Children at Risk for Schizophrenia: A Longitudinal Perspective (pp. 243-263). New York: Cambridge University Press.