Assessing parenting competency in individuals with severe mental illness: a comprehensive service

Links between maternal and child psychopathology symptoms: mediation through child emotion regulation and moderation through maternal behavior

This study examined the intergenerational transmission of psychopathology symptoms with 7-12 year-old children (N = 97; 44 boys, 53 girls, M age = 9.14, SD = 1.38) and their mothers (M age = 38.46, SD = 6.86). Child emotion regulation mediated the links between maternal psychopathology and child internalizing and externalizing symptoms. In turn, the indirect effect was dependent on the level of maternal support in response to youth's expressions of negative emotions when considering particular constellations of maternal reactions and type of psychopathology symptoms. The findings indicate that the relations between maternal and child psychopathology symptoms and child emotion regulation are complex and vary by context. Regardless of the complexity, however, for both internalizing and externalizing symptoms in youth, the results suggest that building adaptive emotion regulation skills is an important target for prevention among children who are at risk for problems due to exposure to maternal psychopathology.

Assessing parenting capacity: are mental health nurses prepared for this role?

Mental health nurses in the UK are involved in the assessment of the parenting capacity of mothers with a serious mental illness in psychiatric facilities. There is evidence that child and family social workers, as the frontline professionals in safeguarding children, rely heavily on the mental health parenting assessment. Parenting assessments have potentially major implications for mother and baby and can lead to the separation of mother and baby. However, there is little or no provision for mental health nurses to undertake this role. In the UK, as in many other countries, there is currently no data as to which psychiatric facilities are conducting parenting assessments nor about the quality of the assessment. There are significant tensions for mental health nurses undertaking parenting assessments and there is no specific training for the role. This paper challenges existing practice, highlights the need for an audit of the current services and recommends the development of a recognized training programme.

Needs of families affected by mental illness

1. To obtain the best outcomes for clients with mental illnesses, the needs of their families must also be assessed and addressed. One basic need is information. 2. Nurses can effectively teach clients and families many skills, including problem solving, parenting, coping with daily living and personal and family stressors, and effective communication. 3. Referring families to appropriate outside resources can provide them with a means of continuing support.

The aftermath: aspects of recovery described by perpetrators of maternal filicide committed in the context of severe mental illness

Mentally abnormal maternal filicide is a rare and horrifying event. Clinicians are unlikely to develop broad experience with this and there is little information available about recovery. This paper presents a range of descriptions of recovery experiences derived from a qualitative study of mentally abnormal maternal filicide perpetrators. Transcripts from a qualitative, semi-structured interview study of six women who committed filicide in the context of major mental illness were reviewed. Descriptions related to rehabilitation issues were grouped and themes extracted. The women described patchy but horrific memories they avoided thinking and talking about. They described intense self-judgement and self-hate. They valued ongoing relationships with surviving children and were distressed by perceptions that they might be a danger to other children. Managing illness was not described as a major challenge. Acknowledgement of illness was described as important in coming to terms with what they had done. Surviving children and relationships with family and other support networks were described as important in their rehabilitation. We conclude that optimizing treatment and rehabilitation for mental illness, supporting the woman to acknowledge the role of illness in the offence, maximizing support from personal networks, and enabling her to regain some aspect of the mother role may be more efficacious than debriefing with respect to the offence.

Parenting programs for women with mental illness who have young children: a review

OBJECTIVE

To provide an overview of the literature relevant to, and describing, parenting programs for women with mental illness who have young children.

METHOD

A literature search was undertaken, including MEDLINE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews and EMBASE: Psychiatry. Searches were limited to English journals and books and to the last five years in the first instance, with earlier literature considered where appropriate.

RESULTS

Maternal mental illness can impact negatively on a child's life, especially where an insecure attachment is formed between mother and baby during the important early developmental years. The potential sequelae of maternal mental illness for children include impaired cognitive development, behavioural difficulties and increased risk of psychiatric disorder. Effective parenting skills are suggested to be a protective factor against these sequelae. However, the effects of parenting programs for women with mental illness have not been empirically tested, so that the potential long-term benefits of such interventions are not known.

CONCLUSIONS

Parenting skills training for women with mental illness may be a useful selective preventive intervention. It is unlikely generic programs will be suitable. Rather, interventions for women with a mental illness will need to address the commonly experienced parenting problems as well as the more specific needs of women with mental illness.

Evaluating the parental fitness of psychiatrically diagnosed individuals: advocating a functional-contextual analysis of parenting

The parental fitness of psychiatrically diagnosed individuals is often questioned in termination of parental rights cases. The goal of this article is to shift the focus from a predisposing bias of unfitness to a functional-contextual analysis of parenting behavior and competency. Three underlying biased assumptions are relevant for the courts' decision making: (a) that a diagnosis (past or present) predicts inadequate parenting and child risk, (b) that a diagnosis predicts unamenability to parenting interventions, and (c) that a diagnosis means the parent is forever unfit. Each assumption will be considered in light of empirical evidence, with major depression, schizophrenia, substance abuse, and mental retardation provided as examples of diagnostic labels often assumed to render a parent unfit. A research agenda to improve clinicians' ability to assess parental fitness and understanding of how parental mental illness, mental retardation, or substance abuse might compromise parenting capacities is discussed for forensic purposes.

Achieving the goal of evidence-based psychiatric rehabilitation practices for mothers with mental illnesses

There is a growing commitment to evidence-based practices in mental health. There is no well-articulated evidence base for interventions for mothers with mental illnesses. Parenthood is common among women with mental illnesses. Women themselves report motherhood is an important role. The risks of parental mental illness to children have been demonstrated; the challenges that motherhood brings to people with mental illnesses have been described. Because outcomes for both children and adults are multiply determined, there are many intervention opportunities. Recommendations for intervention are drawn from a focus group study and from the existing literature on parent training and support, exemplary programs for mothers with mental illnesses, and other evidence-based psychosocial interventions. The value of a psychiatric rehabilitation approach is highlighted. Challenges in documenting and testing interventions for mothers with mental illness include resource allocation and research innovation.

Ethical challenges of decision making with pregnant patients who have schizophrenia

OBJECTIVE

Because there is a dearth of literature, we developed an ethical framework to guide decision making about the management of pregnancy of patients with schizophrenia.

STUDY DESIGN

We review pertinent literature on schizophrenia and pregnancy, including information on maternal and fetal risks and outcomes, and relate this information to ethical concepts.

RESULTS

The ethical framework has five components: the concept of chronically and variably impaired autonomy, assisted decision making, surrogate decision making, strategies for dealing with the physician's feelings in response to these patients, and the concept of the fetus as a patient. We apply this ethical framework to clinical challenges of decision making during pregnancy with this patient population.

CONCLUSIONS

The preventive ethics strategies of assisted and surrogate decision making can be used to prevent ethical conflicts in decision making about the management of pregnancy of patients with schizophrenia. These preventive ethics strategies should contribute significantly to reducing the vulnerability of these patients and therefore to enhancing their autonomy in the physician-patient relationship.

Community mental health care for women with severe mental illness who are parents

Women with SMI are involved in childbearing and childrearing, but may have problems with parenting related to symptoms, lack of knowledge and skills, or lack of environmental supports. They may need intensive services to manage their mental illness and to parent to the best of their abilities. Preliminary research suggests that mental health interventions can improve family functioning, but that these services are not widely available in community mental health systems. This paper describes services to help clients who are parents, which includes integration of adult's and children's services, long-term, home-based parent training, and linkage with community supports.

Advocacy and leadership when parental rights and child welfare collide: the role of the advanced practice nurse

This article describes the experience of an advanced practice nurse in a challenging clinical situation. A mother with mental illness and mental retardation seeks to retain parental rights and care for her newborn with cystic fibrosis. The nurse provides leadership to the hospital team and serves as an advocate throughout legal proceedings. A systematic, nonjudgmental, and empathic approach to gathering information, working with the family, welfare, and legal representatives is described. Enacting a complex and court-mandated homecare education regimen to the disabled mother is discussed. Preparation to testify in a termination of parental rights proceeding is outlined and a summary description of the testimony provided.

Mothers with serious mental illness

Mental health services have generally ignored the parenting needs of women with serious mental illness. This chapter identifies the parenting risks and strengths that these women display, as well as the opportunities available to psychologists to play a key role in improving mother and child outcomes.

Assessing parenting competence in child protection cases: a clinical practice model

Evaluating parents in the context of possible abuse or neglect involves unique challenges. This paper describes a practice model for conducting clinical evaluations of parents' ability to care for young children (under age 8). Core features of the model include (a) a focus on parenting qualities and the parent-child relationship, (b) a functional approach emphasizing behaviors and skills in everyday performance, and (c) application of a minimal parenting standard. Several factors complicate the assessment task, namely, the absence of universally accepted standards of minimal parenting adequacy, the coercive context of the assessment, the scarcity of appropriate measures, difficulties predicting future behavior, and the likely use of the evaluation in legal proceedings. In the proposed model, the evaluator (a) clarifies specific referral questions in advance; (b) uses a multimethod, multisource, multisession approach; (c) organizes findings in terms of parent-child fit; (d) prepares an objective, behaviorally descriptive report that articulates the logic for the evaluator's clinical opinions regarding the referral questions; and (e) refrains from offering opinions regarding ultimate legal issues. The paper describes requisite skills needed to conduct parental fitness evaluations, sample methods, and a protocol for writing the evaluation report.

The evaluation of maternal competency

There is limited discussion of maternal competency in the consultation-liaison psychiatry literature. As awareness and reporting of child abuse is increasing, maternal ability to care for newborns is more often called into question. Maternal risk factors for harm and neglect have been identified, and positive signs of maternal ability have also been recognized as important to appraise. Specific domains in the maternal competency exam should be assessed by the psychiatrist, nursing staff, social work staff and pediatrician. The competency exam by the psychiatrist requires a sensitive and nonjudgmental inquiry into maternal behavior and thoughts. The authors present a case study of an inpatient maternal competency consultation that illustrates some of the dilemmas encountered. Future directions should include more involvement by psychiatrists in preventive efforts and interventions that focus on pregnant women at risk in prenatal clinics and in the community.