Critical Issues for Parents with Mental Illness and their Families

Introduction

Prevalence
Nearly half of the women and men in the United States report a lifetime prevalence of psychiatric disorder, and 30% report the prevalence of at least one disorder in the previous 12 months (Kessler et al., 1997). Two-thirds of these women, and over half of these men are parents (Nicholson, Larkin, Simon, & Banks, 2001). The impact of parental mental illness on family life and children's well being cannot be overstated. The impact of parenting experiences on the well being of adults with mental illness is largely unexplored. Stigma distinguishes mental illness from other serious or chronic conditions like heart disease, diabetes or cancer. Being labeled with a psychiatric diagnosis profoundly negatively affects the experiences of parents and their family members, adults and children alike. However, undiagnosed, untreated mental illness takes its toll on families as well (U.S. Department of Health and Human Services, 1999).

The Problem:
Opportunities for supporting families in which parents have mental illness are missed or lost for many reasons. Ignorance and misinformation about mental illness, pregnancy and parenting, and the ways in which services are organized and policies are implemented compromise outcomes for adults and children. Oftentimes, providers focus on individual patients or clients, rather than on adults with mental illness living in the context of communities and families, and neglect even to ask about family roles and responsibilities (Nicholson, Geller & Fisher, 1996; Nicholson, Geller, Fisher & Dion, 1993). Parents' efforts are overlooked or undermined, families are disrupted, and systems are strained by the burden of providing additional services or alternative placements for children who might otherwise have stayed at home with appropriate family-centered supports. Custody loss rates for parents with mental illness range as high as 70 to 80%; in some states the diagnosis of mental illness alone justifies removal of children from their parents' care (Burton, 1990). The real cost of family disruptions to society and the emotional burden to children and adults are incalculable.

Research clearly indicates that children of parents with mental illness are at increased risk for the development of emotional and behavioral problems. The families of children with serious emotional disturbance served by systems of care across the U.S. report high rates of parental mental illness, psychiatric hospitalization, and substance abuse (Comprehensive Community Mental Health Services Program for Children and Their Families, Annual Report to Congress, 1998). As with any illness, the effects of parental mental illness vary with the ages of adults and their children at illness onset; illness severity and duration; the nature of any consequent impairment in parental functioning; and the strengths and resources of the parents and children.

Children whose parents have mental illness are typically considered to be at risk of developing problems rather than resilient in the face of life challenges. Researchers have focused on the prediction of negative outcomes and the prevention of psychopathology in the next generation, rather than on the identification of individual and contextual characteristics related to positive outcomes, or the evaluation of interventions to support children's resilience and family relationships. Research has demonstrated that some psychiatric disorders have an inherited component, and children whose parents have these mental illnesses may be more likely to develop similar disorders themselves (Biederman et al., 2001). However, the environment in which children grow has as much, if not more, to do with their development and emotional well-being as does the genetic component (Silverman, 1989).

Opportunities:
Because outcomes for these families are multiply determined, there are many opportunities and potentially effective strategies for interventions. Interventions that focus on ensuring a safe, stable home environment, reducing parent-child discord, enhancing parent-child communication, developing parenting skills, reducing environmental stressors, and supporting children's resilience can improve outcomes for parents and children. Efforts to enhance children's understanding of mental illness and parents' understanding of children's needs have shown promising results.

Unfortunately, research often does not inform the development of policies or practices for this population. Nevertheless, a small number of innovative programs target the needs of parents with mental illness and their children. Providers and family members have creatively pieced services together when there were no relevant programs. However, both specialized programs and patchwork efforts are often poorly funded and difficult to sustain. Providers typically compile data on program outcomes specified by funders or agency mandates. Recommendations for best practice are limited by the lack of standardized evaluation data across programs, on outcomes of importance to service recipients as well as to providers and funders. Yet, interventions with adults have worked when their parenting status, goals for themselves and their children, and feelings they have regarding connection, loss or reunification with family members are considered. And children have also shown positive outcomes in programs that focus on the interaction of parental and child well being over the life span. Family-centered intervention strategies, developed for situations in which children have disabilities or illness, are appropriate and can be adapted to situations in which parents are the "identified client."

Parents with mental illness are defined in this report as adults who have ever lived with a psychiatric disorder, and who have ever given birth to or fathered a child. Many may be parents in name only, as other raise their children-foster or adoptive parents, relatives, friends, or strangers. Parents may be in frequent or irregular contact with their young children, be reunited with older children when they become adults, or be totally estranged from family members over a lifetime. Yet, they define themselves as parents rather than patients, and think about, worry about, and sometimes long for their children. Emphasis is placed on the impact of parental mental illness on children as well, who only want to be "the same" as their friends and neighbors, and to have "normal" family lives.

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