Children's perceptions of living with a parent with a mental illness: finding the rhythm and maintaining the frame

Talking and making meaning about parental mental health problems: The role of children's family caregivers

When a parent is less able to meet their children's needs due to a severe and enduring mental health problem (MHP), other adult family members often help with childcare. We present a Grounded Theory of how children's family caregivers construct meaning about the parental MHP and communicate about it with children. Nineteen caregivers participated in qualitative interviews. Each supported at least one related child aged 4-17 years with a parent with MHPs. We found that caregivers engaged in a Core Social Process of providing protection in uncertainty. This comprised three categories as follows: shaping the interactional space, communicating through the developmental process, and engendering a sense of safety. Caregivers appeared to act from a Key Social Positioning of developing a caregiver identity. The findings implicate family-focused provision of mental health and social care. Clinical recommendations are made for whole-family interventions and the role of marital and family therapists.

Constructing the school paradox in the lives of children living with parental mental illness

Children living with parental mental illness are referred to as an invisible population because mental health services rarely target them, as the focus is often on the parent who is ill mentally. The same situation occurs even in school where they are unnoticed. This study conducted in Ghana creates awareness about what these children think about their interactions at school in the context of parental mental illness. Data was collected through interviews and diaries with 13 children living with parental mental illness and analysed to attain the essential features through Husserl's transcendental phenomenology. The children find the school as a happy space where they do not have to be worried about the parent's mental illness. Ultimately, though, even at school, most of the children become concerned about the mental wellbeing of the parent due to their loyalty towards them. This results in the school paradox where the children are torn between having their own time at school and being worried about the parent's condition back home, wanting to be there for the parent. The school paradox is an unhealthy cycle that could be addressed with coordinated efforts from mental health professionals, social workers, psychologists and teachers.

Perceived parental depression, intrusive rumination, and internalizing problems: A three-wave longitudinal study in adolescents

Research suggests that perceiving parental depression elicits internalizing problems in adolescents, but certain studies have indicated that adolescents' internalizing problems also increase their perception of parental emotion. To further investigate the inconsistent findings about the nature of this relationship, the current study used longitudinal data to examine the causal association between adolescents' internalizing problems and the parental depression they perceived, as well as the role of intrusive rumination in the relationship. Method: In this longitudinal study, 392 adolescents who experienced the catastrophic Jiuzhaigou earthquake in 2017 were surveyed at three time points after the earthquake: 12 months (T1), 21 months (T2) and 27 months (T3). A cross-lagged panel model was used to carry out the data analysis. Results: Mutual cause-and-effect relationships were found between intrusive rumination and both perceived parental depression and internalizing problems, respectively; a unilateral causal relationship in which internalizing problems positively predicted perceived parental depression was also found. In addition, internalizing problems predicted perceived parental depression via the mediating role of intrusive rumination; similarly, intrusive rumination predicted perceived parental depression via internalizing problems. Conclusions: Internalizing problems were a risk factor for perceived parental depression, and intrusive rumination played an important role in the relationship between internalizing problems and perceived parental depression.

Parental anxiety and offspring development: A systematic review

BACKGROUND

Parental anxiety has been associated with increased risk of emotional and behavioural problems for offspring, yet the differing impact of each parent is unclear. As emotional disorders continue to present a significant challenge to the health system and with the role of mothers and fathers changing over the past two decades, we sought to systematically review the available literature for an association between parental anxiety and offspring suboptimal outcomes.

METHODS

A systematic review was conducted using the following databases: Ovid MEDLINE, Embase; PsycINFO and Google Scholar. Reference lists of the included papers were also searched. Data was analysed and grouped based on offspring age.

RESULTS

Eighteen studies were included in this review. Results suggest that both parents' mental health can impact negatively on the functioning of offspring, during infancy, childhood, and adolescence. This association is weak in infancy, with equivocal results, however the association in childhood appears robust for both mothers and fathers. In adolescence, the findings suggest that maternal anxiety may be more influential than paternal anxiety.

LIMITATIONS

As the methodology of the included studies was heterogenous, and the timing of assessment varied across the papers, drawing concrete conclusions from the existing research is somewhat impaired.

CONCLUSIONS

Both mothers' and fathers' anxiety have the propensity to negatively impact on their child's development. Implementing preventative interventions, which include both parents, as well as systemic interventions, which include the whole family, are essential in stemming the intergenerational transmission of mental health problems within families.

Obstacles and facilitators to communicating with children about their parents' mental illness: a qualitative study in a sub-district of Mpumalanga, South Africa

BACKGROUND

Given that common mental disorders are one of the leading causes of disease burden worldwide, it is likely that many children are growing up with a parent or other adult within their family who has anxiety or depression. Parents with a mental illness may not consider it appropriate to discuss their illness with their child, and consequently an absence of communication may lead to stigmatization, shame, misunderstanding their parents' symptoms, and even blaming themselves. There is a scarcity of research exploring the experiences and perceptions of healthcare professionals about communication with children of parents with mental illness in low-resource and African contexts.

METHODS

A qualitative study using semi-structured interviews with healthcare professionals (n = 15) was conducted within the Bushbuckridge sub-district of Mpumalanga Province, South Africa. Data were analysed using Thematic Analysis.

RESULTS

Four themes were identified relating to the obstacles around communication with children. These included: (1) finding an appropriate language to describe mental illness, as well as the prevailing cultural explanations of mental illness (2) the stigma associated with mental illness (3) the perceived role of children in society and (4) mental health services and staff skills. Two themes that addressed facilitators of communication about parental mental illness were identified: (1) the potential to increase mental health awareness amongst the broader community through social media, the internet, and general psychoeducation (2) healthcare professionals' concerns for the wellbeing and future mental health of patients' children, as well as their hopes for increased mental health awareness amongst future generations.

CONCLUSIONS

This study provides insight into healthcare professionals' attitudes and perceptions about talking to patients and families within their community about mental illness. The results provide recommendations about possible ways to promote sharing information about a parent's mental illness with children at an individual and community level. Future research should focus on the collaborative creation of culturally sensitive psychoeducational resources and evidence-based guidelines. This must be supported by systemic and organisational change in order for professionals to successfully facilitate conversations with patients who are parents, and their children.

A family perspective on parental psychosis: An interpretative phenomenological analysis study

OBJECTIVES

While one third of people with a psychotic disorder are a parent, there has been little research to date examining the consequences of this from a whole family perspective. This study investigates families where a parent has experienced an episode of psychosis and compares and contrasts the family members' perspectives.

DESIGN

This study was rooted in phenomenology and data were derived from in-depth semi-structured interviews.

METHODS

Parents with a psychotic disorder who had a child aged between 3 and 11 in a UK NHS Trust were invited to take part in the study. Semi-structured interviews were conducted with these parents, with their child (if they were between the ages of 8 and 11), and with their partner or another close family member. Data were analysed using multiperspectival interpretive phenomenological analysis (m-IPA).

RESULTS

Thirteen participants took part comprising of five parents, four children, three partners and one grandmother. Four themes were developed using m-IPA: (1) Parental psychosis impacts the whole family, (2) Psychosis and my role as a parent, (3) Secrecy and concealment surrounding parental psychosis, and (4) Pressures and vulnerabilities within the family system.

CONCLUSION

Psychosis had a negative impact on all family members and secrecy existed between family members. The children in particular only had partial information about their parent's mental illness, which left them worried and confused. More work is needed to support these families to explain psychosis to the children.

[Psychological Abnormalities in Children from the Perspective of Parents with a Mental Disorder]

BACKGROUND

There is increased risk for children with a mentally ill parent to get a mental illness. In Germany, it is assumed that the risk for psychological abnormalities in children with a mentally ill parent is increased by a factor of 2,4. The aim of this study was to give an overview of psychological abnormalities in children with mentally ill parents.

METHODS

Patients were asked about their children and possible psychological abnormalities in their children during their stay in a psychiatric ward. Data of n=118 children (51,7%) of psychiatric inpatients could be used for analyses.

RESULTS

One-fourth of the children showed psychological abnormalities. According to their parent, one fourth was also in psychotherapeutic/psychiatric treatment. There were no differences in the abnormalities associated with sociodemographic factors of the parent.

CONCLUSION

Our results show that children of a mentally ill parent also suffer from psychological abnormalities. More explicit analyses of the care situation of these children as well as data from direct interviews with them are needed.

How Do Children of Parents With Mental Illness Experience Stigma? A Systematic Mixed Studies Review

Stigma can have devastating health and wellbeing impacts, not just on people with mental health problems, but on people associated with the stigmatized person. This is called stigma-by-association. Children whose parents have mental health problems are a particularly vulnerable group, and stigma acts as a mechanism, contributing to the transgenerational transmission of mental disorders. The current study is a systematic mixed studies review, synthesizing knowledge about how this group of children experience stigma-by-association. Overall, 32 studies were included, after a systematic search including quantitative, qualitatative, and mixed methods studies. The methodological quality was assessed and qualitative content analysis undertaken. We grouped children's stigma experiences into four dimensions, i.e., experienced stigma, anticipated stigma, internalized stigma, and structural discrimination. Results show that stigma is an important factor in those children's lives, and needs further investigation in qualitative and quantitative research. The current study emphasizes the importance of anti-stigma interventions and campaigns.

Family Talk versus usual services in improving child and family psychosocial functioning in families with parental mental illness (PRIMERA-Promoting Research and Innovation in Mental hEalth seRvices for fAmilies and children): study protocol for a randomised controlled trial

BACKGROUND

Parental mental illness is common and can lead to dependent children incurring a high risk of developing mental disorders, physical illness, and impaired educational and occupational outcomes. Family Talk is one of the better known interventions designed to prevent the intergenerational transmission of mental illness. However, its evidence base is small, with few robust independent randomised controlled trials, and no associated process or cost evaluations. The PRIMERA (Promoting Research and Innovation in Mental hEalth seRvices for fAmilies and children) research programme involves a mixed method evaluation of Family Talk which is being delivered in mental health settings in Ireland to improve child and family psychosocial functioning in families with parental mental illness.

METHODS

The study comprises a multi-centre, randomised controlled trial (RCT), with nested economic and process evaluations, to assess the clinical and cost-effectiveness and implementation mechanisms of Family Talk compared to usual services. The study is being conducted in 15 adult and child mental health settings in Ireland. Families with a parent with mental illness, and children aged 5-18 years (n = 144 families) will be randomised to either the 7-session Family Talk programme (n = 96) or to standard care (n = 48) using a 2:1 allocation ratio. The primary outcomes are child psychosocial functioning and family functioning. Secondary outcomes are as follows: understanding and experience of parental mental illness, parental mental health, child and parental resilience, partner wellbeing and service utilisation. Blind assessments will take place at pre-intervention and at 6- and 12-month follow-up.

DISCUSSION

Given the prevalence and burden of intergenerational mental illness, it is imperative that prevention through evidence-based interventions becomes a public health priority. The current study will provide an important contribution to the international evidence base for Family Talk whilst also helping to identify key implementation lessons in the scaling up of Family Talk, and other similar interventions, within routine mental health settings.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN13365858 . Registered 5th February 2019.

The Long-Term Impact of Parental Mental Health on Children's Distress Trajectories in Adulthood

Using six waves of data from the Panel Study of Income Dynamics (2007-2017) and the Childhood Retrospective Circumstances Study (2014) (n=3,240), this paper estimates how childhood experiences with parental mental health problems shape trajectories of children's own distress in adulthood. Findings indicate that those who experience poor parental mental health have consistently greater distress than their non-exposed counterparts throughout adulthood. More severe and longer exposures to parental mental health problems corresponds to even greater distress in adulthood. The gender of the parent afflicted does not predict differences in adult mental health, but those individuals exposed to both maternal and paternal poor mental health have the greatest distress in adulthood. Together, results suggest that parental mental health during children's formative years is a significant predictor of life course distress and that heterogeneity in this experience corresponds to unique mental health trajectories.

'I have cried a lot': a qualitative study on children experiencing severe parental illness

BACKGROUND

A considerable body of research has explored implications of severe parental illness on children. However, less is known about what children and adolescents with a severely ill parent experience as the most challenging.

AIMS

To describe what children with a severely ill parent experience as their most difficult challenge.

METHODS

A qualitative descriptive design with a manifest content analysis was used on data from a cross-sectional, multicenter study on children of patients in five Norwegian Health trusts. Data consisted of written textual responds from 238 children (age 8-18) to one open-ended question in a self-report questionnaire.

RESULTS

The overall theme concerning the children's most difficult challenge was named 'the drama of life unfoldment', reflecting the parental illness' impact on themselves, their relationships with others, and their life circumstances. The subthemes consisted of: Children's experiences of difficult thoughts and feelings; negatively impaired relationship with parents, friends and others; and challenging life events and obstacles in welfare.

CONCLUSIONS

The most difficult challenge experienced by the children with a severely ill parent implies life unfoldment challenges and include negative personal and relational impact, challenging life events and obstacles in welfare.

Children of parents who have been hospitalised with psychiatric disorders are at risk of poor school readiness

AIMS.

Children of parents with psychiatric disorders are at risk of poor outcomes. However, there is limited evidence regarding the relationship between parental psychiatric disorders and child school readiness, which is linked to later academic achievement. This study aims to investigate these relationships and broaden the evidence underlying the rationale for family-focused interventions for parental psychiatric disorders.

METHOD.

This study used linked administrative data. Children's school readiness in multiple developmental domains (physical, social, emotional, communicative, cognitive) was measured by the Australian Early Development Census (AEDC) for 19 071 Western Australian children (mean age 5.5 years). Children scoring in the bottom 25% on any AEDC domain were considered developmentally vulnerable, or at risk of vulnerability, on that domain. Biological child-parent pairs were identified using birth records. Parents with psychiatric disorders were identified from hospital records, which included information on diagnosis and frequency/duration of psychiatric admissions. Logistic regressions, adjusted for parent age, mother's marital status, child Aboriginality, child English language status, local community remoteness and socioeconomic index, estimated the odds of children being vulnerable/at-risk on each of the AEDC domains.

RESULTS.

A total of 719 mothers and 417 fathers had a psychiatric hospitalisation during the study period (12 months prior to the child's birth, up to the end of 2009). Children whose parents had psychiatric disorders had increased odds of being classified as vulnerable/at-risk for school readiness. This increase in odds was evident for both maternal (adjusted odds ratio, aOR 1.37- 1.51) and paternal psychiatric disorders (aOR 1.38-1.50); and for a single admission of one day (aOR 1.32-1.59), a single admission of multiple days (aOR 1.30-1.47), and multiple admissions (aOR 1.35-1.63). Some variability in child outcome was found depending on the parents' psychiatric diagnosis (mood, anxiety, substance abuse or comorbid disorder).

CONCLUSIONS.

Children of parents who have been hospitalised with psychiatric disorders are at risk for poor school readiness. These findings add support to recommendations that mental health professionals consider dependent children in discharge and treatment planning for adult psychiatric inpatients. It is also important to ensure that the impact of psychiatric illness in fathers is not overlooked in assessment and intervention. Family-based approaches to adult psychiatric care could meet the dual needs of intervention for parents and preventative measures for children. These findings can inform policy regarding the importance of integrating and coordinating services to meet the needs of families.

Mental Health Literacy of Youth That Have a Family Member With a Mental Illness: Outcomes From a New Program and Scale

A program evaluation examined mental health literacy levels and coping outcomes for youth (ages 10-16), before and at the end of their participation in a manualized, school-based mental health literacy program called Youth Education and Support (YES). Most of the youth reportedly had a parent or other family member with a mental health disorder such as depression, anxiety, and/or substance abuse. The mental health literacy levels of program participants from pre to post were evaluated with the developing Knowledge of Mental Illness and Recovery (K-MIR) scale. This scale was validated using item-response theory, demonstrating good psychometric properties. Youth answered two coping questions about their use of positive coping during the program and coping skills compared from pre to post intervention. Findings revealed that youth levels of mental health literacy increased significantly from pre to post program participation. Over 90% of the youth reported an improved use of positive coping strategies from pre to post intervention. The program appeared to deliver enhanced levels of literacy and coping for this sample of youth. The scale appeared to be appropriate to measure youth mental health literacy. Recommendations for practice, policy, and research are offered.

School performance from primary education in the adolescent offspring of parents with schizophrenia and bipolar disorder- a national, register-based study

BACKGROUND

Schizophrenia (SZ) and bipolar disorder (BP) are causes of severe disability worldwide and parents' severe mental illness (SMI) is associated with childhood adversity, and socio-emotional and cognitive problems in children. Yet, how parental BP and SZ affect educational attainment in offspring is still unclear.

METHOD

We included all children (N = 684.248) born and living in Denmark between 1986 and 1996 and their parents. Our follow-up lasted from 1986 until children's graduation in 2014. The main outcome variable was their school grades following their primary education. School outcomes were divided into four categories: not graduated, low-grade point average (GPA), medium GPA and high GPA. We then performed a multiple logistic regression with medium GPA as the reference category, with the children of parents without SZ or BP as the reference group.

RESULTS

Children of parents with SZ faced higher odds than their peers of not graduating primary education (OR 2.6), along with low GPA (odds ratios (OR) 1.6) and lower odds for a high GPA (OR 0.7). Moreover, it was the children of mothers rather than fathers with BP who had higher odds of not graduating primary education (OR 1.6). Lastly, child placement was associated with lower grades and lower graduation rates, and outcomes for children of parents with SMI were favorable compared with other children placed in care.

CONCLUSION

For children, parental SZ is associated with lower grades and lower chances for graduating primary education. In contrast, the children of parents with BP were indistinguishable from the reference group regarding school grades. This signifies that specificity of parental severe mental illness is important in relation to educational achievement of children.

Talking to children about parental mental illness: The experiences of well parents

BACKGROUND

Children of parents with mental illness are not routinely included in psychoeducational and supportive family interventions provided by adult mental health systems. The family, therefore, is an important and, sometimes, the only source of information and support for them.

AIM

To understand the experiences of well parents in talking to their children about parental mental illness.

METHOD

This article presents the findings of a qualitative study of the experiences of well parents in talking to their children about parental mental illness. Ten well parents whose spouses were diagnosed with a severe mental illness participated in the study. Socio-demographic information, family details and history of the spouse's mental illness along with their experiences of talking to children about parental mental illness, the perceived risks and benefits, challenges they faced and the role of others in the process were recorded. Qualitative data were analysed using interpretative phenomenological analysis.

FINDINGS

The themes of 'distancing children from parental mental illness', 'avoiding conversations about the illness', 'giving and receiving emotional support', 'providing explanations of the illness' and 'regulating other sources of information' show the complex ways in which well parents influence their children's understanding of parental mental illness. The findings are examined in the background of what is known about this topic from the perspective of children or of the parent with illness. Possible ways to support well parents in families affected by parental mental illness are discussed.

CONCLUSION

This study is a step forward in the understanding of how families talk to children about parental mental illness and provides the perspective of the well parent.

Children's experiences of living with a parent with mental illness: A systematic review of qualitative studies using thematic analysis

WHAT IS KNOWN ABOUT THE SUBJECT?: There are many qualitative studies that explore what it is like for children who live with a parent who has a mental illness. These studies are sometimes criticized because they have small sample sizes which limits their application. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We conducted a systematic review of qualitative papers with an aim to strengthening our understanding of what it is like for children who live with a parent who has a mental illness. We used stringent criteria to make sure that only the voices of children affected by parental mental illness were included in the review. In addition, the paper presents a timely update on previous reviews completed in this area. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings of this review highlight the impact that parental mental illness has on children and the important role that mental health nurses can play in maximizing opportunities for building resilience in affected children. Mental health nurses are in a key position to provide timely and age-appropriate information and support to both parents and children to assist in the development of appropriate coping and support mechanisms.

ABSTRACT

Introduction This paper brings together what is known about what it is like for children who live with a parent with a mental illness with a view to strengthening our understanding of their experiences. This paper presents an update on previous reviews that were completed in this area and used a systematic approach and stringent inclusion/exclusion criteria to ensure that the voices of children were central in the included papers. A systematic review of this nature could not be located in the literature. Aims This paper presents the findings of a systematic review which explored the experiences of children who were affected by parental mental illness. Methods CINAHL, PubMed, PsychINFO, Pubmesh and EMBASE were searched for qualitative studies which explored children's experiences, and eight studies were included following review and quality appraisal. Pertinent data were extracted, coded and analysed using a thematic approach. Results Four themes emerged from the analytic process which described the children's understanding of mental illness, their relationship with their parents, their coping strategies and their social connections. Implications for Practice Mental health nurses need to recognize the psychosocial needs of children, and to acknowledge, the wider impact mental illness has of the family.

How Do Children Make Sense of their Parent's Mental Health Difficulties: A Meta-Synthesis

Children of parents who experience mental health difficulties (COPE-MHD) consistently demonstrate numerous negative outcomes, including risks of intergenerational continuity of mental health difficulties (MHD). Numerous studies have analysed the experiences and understanding of parents' MHD from the perspective of COPE-MHD. This metasynthesis aims to capture, across available literature, the way in which COPE-MHD make sense of their parent's MHD and how this perception impacts their life. For inclusion in the review, research articles were required to be published in peer-reviewed journals, apply qualitative methods of data collection and analysis and report on the direct accounts of COPE-MHD regarding their understanding or experience of their parents' MHD. Five electronic databases were used; Academic Search Complete, CINAHL, MEDLINE, PsycINFO and Child Development and Adolescent Studies. Fourteen studies were included. Analysis produced three overarching themes. The findings illustrate children's sophisticated biopsychosocial conceptualisation of the cause and process of their parent's MHD. It also highlights how they utilise this understanding to manage the day-to-day concerns associated with their parent's experience of MHD. Clinical implications highlight a need for services working with children, parents and families to more frequently enquire about parents' MHD and to consider the outcomes of such enquiry in the psychological formulation of children and young peoples' mental health and development. Limitations and recommendations for future research are presented.

Mental Health Literacy Content for Children of Parents with a Mental Illness: Thematic Analysis of a Literature Review

Millions of children have a parent with a mental illness (COPMI). These children are at higher risk of acquiring behavioural, developmental and emotional difficulties. Most children, including COPMI, have low levels of mental health literacy (MHL), meaning they do not have accurate, non-stigmatized information. There is limited knowledge about what kind of MHL content should be delivered to children. The aim of this exploratory study is to identify the knowledge content needed for general population children and COPMI to increase their MHL. A second aim is to explore content for emerging children's MHL scales. Researchers created and analyzed a literature review database. Thematic analysis yielded five main mental health knowledge themes for children: (1) attaining an overview of mental illness and recovery; (2) reducing mental health stigma; (3) building developmental resiliencies; (4) increasing help-seeking capacities; and (5) identifying risk factors for mental illness. COPMI appeared to need the same kind of MHL knowledge content, but with extra family-contextual content such as dealing with stigma experiences, managing stress, and communicating about parental mental illness. There is a need for MHL programs, validated scales, and research on what works for prevention and early intervention with COPMI children.

Young children's experiences of living with a parent with bipolar disorder: Understanding the child's perspective

OBJECTIVES

To explore the experiences of young children of living with a parent with bipolar disorder (BD) and how this impacts on their emotional well-being.

DESIGN

Qualitative study using a computer-assisted semi-structured interview, 'In My Shoes' (IMS).

METHODS

Ten children aged between 4 and 10 years with a parent with BD identified via self-help groups were interviewed about their experience of family life. Thematic analysis was used following transcription.

RESULTS

Four main themes emerging from thematic analysis were as follows: perception of parents; knowledge and awareness of BD; managing family life with a 'bipolar' parent; and living in a family with BD. Four-year-old children could participate in the IMS interviews and discuss their parent's mood, behaviour, and mental health. Children had candid and insightful discussions about their parent's BD including symptoms and parenting, and could reflect on how having a parent with BD affected them emotionally and practically. Older children were better able to articulate their parent's illness and its impact.

CONCLUSIONS

This exploratory study represents an important step in examining directly experiences of young children whose parents have BD. Using IMS, it was possible to gather insightful information from children to generate hypotheses and influence service development. Children of all ages had some knowledge and understanding of their parent's illness, describing both positive and negative experiences in the family. Further research to build understanding of children's perspectives and the support they feel they and their family would benefit from would enhance the development of appropriate services and interventions.

PRACTITIONER POINTS

Using age-appropriate tools, it is possible to elicit the views of young children about their parent's mental health and parenting. Young children have insight into the impact of bipolar disorder in the family on themselves and family members.

Involvement and Warmth of Fathers with Mental Illness: The Role of the Caregiving System, Parental Self-Efficacy, Social Support and Child Characteristics

This study compares the levels and predictors of paternal warmth and involvement of 69 fathers with serious mental illness (SMI) and 69 matched non-clinical (NC) fathers in Israel. Findings show that the NC fathers were more involved with their children, whereas the SMI fathers reported more warmth and perceived their children as less difficult. The interactions that were found in the regression analyses highlight the differences between the two groups. Among the SMI fathers, but not the NC fathers, higher paternal self-efficacy was associated with increased father involvement, and lower family support was associated with decreased warmth.

Talking or Keeping Silent About Parental Mental Health Problems-A Grounded Theory of Parents' Decision Making and Experiences with Their Children

This grounded theory study explored parents' experiences of responding to their children's need for understanding parental mental health concerns. Fifteen parents with severe and enduring mental health difficulties participated in the study. The findings suggest four main social processes that influence parents' talk with their children about parental mental health issues, namely "Protecting and being protected," "Responding to children's search for understanding," "Prioritizing family life," and "Relating to others." Implications of the findings for clinical practice and future research are considered. In particular, the need for more family-orientated services where parents experience parental mental health problems is highlighted.

Children of parents with alcohol problems performing normality: A qualitative interview study about unmet needs for professional support

BACKGROUND

Children of parents with alcohol problems are at risk for serious long-term health consequences. Knowledge is limited about how to recognize those in need of support and how to offer respectful services.

METHOD

From nine interviews with adult children from families with alcohol problems, we explored childhood experiences, emphasizing issues concerning potentially unmet needs for professional support. Smart's perspective on family secrets and Goffman's dramaturgical metaphor on social order of the family focusing on the social drama and the dramaturgy enacted by the children supported our cross-case thematic analysis.

FINDINGS

The social interaction in the family was disrupted during childhood because of the parent's drinking problems. An everyday drama characterized by tension and threats, blame and manipulation was the backstage of their everyday life. Dealing with the drama, the children experienced limited parental support. Some children felt betrayed by the other parent who might trivialize the problems and excuse the drinking parent. Family activities and routines were disturbed, and uncertainty and insecurity was created. The children struggled to restore social order within the family and to act as normally as possible outside the family. It was a dilemma for the children to disclose the difficulties of the family.

CONCLUSION

Altogether, the children worked hard to perform a normally functioning family, managing a situation characterized by unmet needs for professional support. Adequate support requires recognition of the children's efforts to perform a normally functioning family.

Self-expressed strengths and resources of children of parents with a mental illness: A systematic review

The aim of the present study was to explore the strengths children reported to have acquired while coping with their parents illness, and the external factors these children indicated had facilitated their coping process. A systematic literature search was conducted of peer-reviewed papers that focused on self-reported experiences of children with parents who had mental illness, and revealed their strengths and resources. The search included the following databases: MEDLINE, PsycINFO, and CINAHL. Results were filtered according to whether search terms appeared in the title or abstract. Fifty-seven full-text papers were reviewed; 26 of them met the inclusion criteria and were included in the review. The statements were analysed using content analysis. The search identified 160 relevant statements, 38 (24%) of which could be described as self-reported strengths, and 122 (76%) as self-reported resources. According to these statements, the children described themselves as more mature, independent, and empathic than their peers who did not have a parent with a mental illness, and as having acquired several abilities. The statements about resources indicated that the children regarded social support, information, and particularly the support of mental health-care professionals as helpful when living with a parent with a mental illness. Recommendations for nursing actions to support children's ability to cope with their parents' illness are outlined.

Navigating in an unpredictable daily life: a metasynthesis on children's experiences living with a parent with severe mental illness

A large group of individuals suffering from mental illness are parents living with their children. These children are invisible in the health care even though at risk for illhealth. The aim of this metasynthesis was to advance knowledge of how children of parents with mental illness experience their lives, thus contributing to the evidence of this phenomenon. The metasynthesis is following Sandelowski and Barroso's guidelines. Literature searches covering the years 2000 to 2013 resulted in 22 reports which were synthesised into the theme 'navigating in an unpredictable everyday life' and the metaphor compass. Children of parents with mental illness irrespective of age are responsible, loving and worrying children who want to do everything to help and support. Children feel shame when the parent behaves differently, and they conceal their family life being afraid of stigmatisation and bullying. When their parent becomes ill, they distance to protect themselves. The children cope through information, knowledge, frankness and trustful relationships. These children need support from healthcare services because they subjugate own needs in favour of the parental needs, they should be encouraged to talk about their family situation, and especially, young children should to be child-like, playing and seeing friends.

Toward Understanding the Child's Experience in the Process of Parentification: Young Adults' Reflections on Growing up With a Depressed Parent

This article reports on a qualitative study with 21 young adults who grew up with a depressed parent. We examined how young adults make sense of their childhood experiences of parental depression and how their retrospective reflections help us to understand the experiences of children and the processes of parentification. Participants recounted that their childhood consisted mainly of actions in the service of family well-being. At that time, they reflected on their own experiences only rarely. In adolescence, there was an evolution toward a greater consideration for oneself and a repositioning within the family. In the discussion, we explore the therapeutic implications of this study--and in particular--the meaningfulness of silence in the family process of parentification.

A Dynamic Cycle of Familial Mental Illness

In this paper, we present A Dynamic Cycle of Familial Mental Illness; an innovative framework, which considers family members' experiences and responses to mental illness. There is an acknowledged discourse noting parental experiences of mental illness alongside a growing body of knowledge acknowledging children's needs while living with parental mental illness. However, there is a paucity of literature that makes reference to the concept of familial mental illness and the cyclic interface of parental and child distress and symptoms. The model is supported by published research studies from several differing disciplines to demonstrate the relationship between parent and child experiences and to synthesise the published short- and longer-term possible impact of familial mental illness. An extensive search of the literature using recognised search engines, keywords and phrases has been undertaken, to generate an appropriate literature base for this work. This literature demonstrates how a child's possible emotional distancing as a response to parental mental illness could increase parental distress. A Dynamic Cycle of Familial Mental Illness adopts the underpinning philosophy of a Stress Vulnerability Model of Mental Illness, which assumes that predisposing factors and increased stress for a parent may have possible links to exacerbation of parental mental distress and symptomology. We advocate for further research of familial mental illness, and argue for a family approach to mental health assessment and treatment in mainstream health and social care sectors.

Communal normalization in an online self-help group for adolescents with a mentally ill parent

Although implications of parental mental illness are well documented, most children of mentally ill parents are left to manage their family situation with limited information and support. We explored the role of a Norwegian online self-help group for adolescents (aged 15 to 18) with a mentally ill parent. Through in-depth interviews with 13 participants, we found that the online self-help group provided "communal normalization" by which participants, through communication in the forum, made sense of everyday experiences and emotions arising from having a mentally ill parent. We identified three main aspects of this process-recognizability, openness, and agency-all of which were important for the adolescents' efforts to obtain support, to be supportive, and to handle everyday life situations better. Communal normalization might provide resources for significantly improving the participants' life situations, and could demonstrate similar potential for users in other situations characterized by stigma, loneliness, silence, and health worries.

Analysis of a support group for children of parents with mental illnesses: managing stressful situations

We report an ethnographic analysis of a psycho-education and peer-support program for school-aged children of parents with mental illnesses. We conducted a critical discourse analysis of the program manual and observed group interactions to understand whether children shared program goals predetermined by adults, and how, or if, the intervention was responsive to their needs. Children were expected to learn mental illness information because "knowledge is power," and to express difficult feelings about being a child of a mentally ill parent that was risky. Participants used humor to manage group expectations, revealing how they made sense of their parents' problems, as well as their own. Suggestions are made for determining good mental health literacy based on children's preferences for explaining circumstances in ways they find relevant, and for supporting children's competencies to manage relationships that are important to them.

Effectiveness of preventive support groups for children of mentally ill or addicted parents: a randomized controlled trial

In various countries preventive support groups are offered to children of mentally ill and/or addicted parents to reduce the risk that they will develop problems themselves. This study assessed the effectiveness of Dutch support groups for children aged 8-12 years old in terms of reducing negative cognitions; improving social support, competence, and parent-child interaction (direct intervention goals); and reducing emotional and behavioural problems (ultimate intervention aim). Children from 254 families were randomly assigned to the intervention or a control condition. Parents and children completed questionnaires at baseline and 3 and 6 months later. Emotional and behavioural problems of intervention group children were also assessed 1 year after the start. Univariate analyses of variance showed that children in the intervention group experienced a greater decrease in negative cognitions and sought more social support, immediately after participation and 3 months later, as compared to control group children. They also remained stable in their feelings of social acceptance (competence aspect) immediately after the intervention, whereas these feelings declined in control group children. The intervention and control groups both improved over time in terms of cognitions, competence, parent-child interaction and emotional and behavioural problem scores. Additional improvement in terms of problem scores was found in the intervention group 1 year after baseline. Further enhancement of effectiveness requires re-consideration of the support group goals; it should be studied whether the goals reflect the most important and influential risk and protective factors for this specific population. Besides, effects should be studied over a longer period.

Trying to comfort the parent: a qualitative study of children dealing with parental depression

In this article, we look at children's experiences of parentification in families in which one of the parents is hospitalized for depression. Children (7-14 years old) and their parents were invited for a family interview. Using thematic analysis, we constructed a general framework of 14 children's experiences, guided by the explorative research question: How do children experience parental depression and how do they experience their own caregiving in the family? The thematic analysis revealed eight themes. One of these themes (trying to comfort the parent) was selected for a microanalysis in one family interview. Our study illustrates the process of overt negotiating of caretaking between parent and child with an underlying moral dilemma and related emotions. The dynamic of children hiding their worry can be seen as an answer to the parent's expressed wish to not burden her children. These dynamics are situated in ongoing debates in family therapy literature, and some suggestions for therapeutic practice are formulated.

Engaging with, and understanding children whose parents have a dual diagnosis

BACKGROUND

  The perspective of children whose parents have a mental health and a substance use disorder (dual diagnosis) are rarely considered in either research or clinical practice. This study sought to (i) identify the issues when engaging children whose parents have a dual diagnosis into research, and (ii) present their needs and preferred supports.

METHOD

  Semi-structured, qualitative interviews were conducted with 12 children whose parent had a dual diagnosis. Analyses involved thematic analysis, inter-rater reliability and respondent validation.

RESULTS

  Building trust with parents was crucial to gain access to children. Children described the importance of family, the secrecy around their parent's substance abuse, and various maladaptive coping strategies. Children requested more positive times in their families and specific support for their parent's substance abuse.

CONCLUSION

  The primacy of family in the child's life is highlighted. The need to acknowledge and work with the individual needs of children and parents, as well as family dynamics, is indicated.

Living with parents with obsessive-compulsive disorder: children's lives and experiences

BACKGROUND

It has been well documented that parental mental health problems can lead to adverse consequences for their children. However, few studies have examined the subjective experiences of these children. Several parental mental health problems have been studied, but obsessive-compulsive disorder (OCD) has primarily been considered in relation to adult relatives of the sufferer only.

AIMS

This study aimed to explore the experiences of young people with a parent with OCD, including the impact of parental OCD and their understanding of it.

METHOD

Semi-structured interviews were conducted with ten 13- to 19-year-olds with a parent with OCD. The data were analysed using inductive thematic analysis.

RESULTS

Five themes were identified: 'Control and boundaries'; 'Doing what I can to help'; 'Telling: embarrassment and pride'; 'Do I have OCD?'; and 'Getting the right help for me'.

CONCLUSIONS

Parental OCD presented challenges to participants and placed burden upon them, for which they did not receive adequate support. The issues raised by parental OCD seemed similar to other parental mental health problems, but the results suggested that the child's developmental stage may be a significant influence.

Distressed fathers and their children: a review of the literature

BACKGROUND

Many men diagnosed with mental health problems are also fathers. This literature review addresses issues relating to both the fathering role taken on by men who have mental health problems as well as the impact of their mental health on their children.

MATERIAL

An integrative review of the literature was conducted from studies originating in four countries, resulting in an analysis of 31 journal articles.

DISCUSSION AND CONCLUSIONS

Most of the quantitative literature focuses on the many risks and negative outcomes for children. However, qualitative studies suggest positive outcomes such as strong parent-child relationships, which demand further attention both in research and in practice.

Living with a mentally ill parent: exploring adolescents' experiences and perspectives

Although a considerable body of research has described the implications of parental mental illness, the perspectives of children and adolescents have rarely been addressed. In this article, I explore adolescents' experiences in everyday life, based on an action-oriented study of a Norwegian online self-help group for adolescents (aged 15 to 18) with mentally ill parents. The analysis was conducted through participant observation of the group for 2 years. The adolescents experienced a variety of difficult challenges related to their parent's mental illness: lack of information and openness; unpredictability and instability; fear; loneliness; and loss and sorrow. However, they also discussed strategies for active management of the challenges arising from the family situation. I argue that these adolescents can be understood as vulnerable as well as active participants in managing their everyday lives. I emphasize the importance of including perspectives of children and adolescents in further research so as to improve health care for families with parental mental illness.

Children's experiences of parental mental illness: a literature review

AIM

This paper provides a review of published qualitative research on children's experiences of parental mental illness.

METHODS

We undertook a comprehensive search of Medical Literature Analysis and Retrieval System Online, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts and Applied Social Sciences Index and Abstracts databases, as well as citation searches in Web of Science and manual searches of other relevant journals and reference lists of primary papers.

RESULTS

Although 20 studies met the search criteria, only 10 focused exclusively on children's descriptions of their experience--the remainder elicited adults' perspectives on children's experiences of parental mental illnesses. Findings are organized under three themes: the impact of illness on children's daily life, how children cope with their experiences and how children understand mental illness.

CONCLUSIONS

Despite references to pervasive knowledge gaps in the literature, significant information has been accumulated about children's experiences of parental mental illness. Considerable variability in research findings and tensions remain unresolved. For example, evidence is mixed as to children's knowledge and understanding of mental illnesses and how best to deploy resources to help them acquire optimal information. Furthermore, children's desire to be recognized as important to their parents' well-being conflicted with adults' perceptions that children should be protected from too much responsibility. Nevertheless, the cumulative evidence remains a key reason for advocating for psychoeducation and peer-support group interventions for children, which are endorsed by child and adult study participants alike.

A qualitative meta-synthesis of adult children of parents with a mental illness

AIMS AND OBJECTIVES

This article presents a qualitative meta-synthesis that explores the experiences of adult children of parents with a mental illness.

BACKGROUND

There has been growing interest in the experiences of children whose parents have mental illness. However, little literature explores the experiences of adult children.

DESIGN

Qualitative meta-synthesis.

METHOD

A review of English language literature search engines was undertaken and identified 905 relevant articles. Articles were excluded if they used quantitative methodology, had other methodological issues or had a focus on parental drug/alcohol issues. Twelve articles were identified as using qualitative or mixed methods studies, which were reviewed using the Critical Appraisal Skills Programme (Public Health Resource Unit 2006). Following this, seven studies were included in the meta-synthesis. The main findings and themes identified by the original study authors were extracted from the results and discussions sections and further categorised into four main themes using content analysis methods.

RESULTS

There were 26 themes identified by the meta-synthesis, which were collated into four wider categories and concepts. Issues related to family relationships, external familial relationship changes, the adult child's emotional reflections and illness-related concepts were identified.

CONCLUSION

There is a paucity of qualitative research that considers adult children's experiences of parental mental illness. In the available studies, issues related to family relationships, external familial wider relationship changes, the adult child's emotional reflections and illness-related concepts were identified as being of concern to adults who experienced parental mental illness during childhood.

RELEVANCE TO CLINICAL PRACTICE

There is a need for all health and social care services to be aware of the experiences/needs of adult children who have experienced parental mental illness. Adult children of parents with mental illnesses should be provided with opportunities to discuss their stories to validate their experiences.

Children's view of a major depression affecting a parent in the family

This study aims to elucidate, from the children's perspective, the meaning for family life of a parent suffering a major depression disorder. Eight children and young adults were interviewed. Phenomenological-hermeneutic analysis generated two themes: (1) "Being a rescuing observer" with the subthemes, "Being attentive" and "Being considerate," and (2) "Being a frustrated observer" with the subthemes, "feeling discomfort" and "being out of it." Children's lives alternate between responsibility and loneliness as they wait for reciprocity in family life to return to normal. Children need support in order to manage their sense of responsibility and loneliness adequately.

Emerging adulthood and the perception of parental depression

Few studies have examined children's perceptions of parental depression. This study was a qualitative analysis of the changes in the perception of parental depression between the ages of 17 and 19 years. Archived interview narratives of 16 respondents from a longitudinal, preventive intervention study of depression in families were analyzed. The respondents were purposefully selected to represent both genders as well as higher and lower levels of family adversity. The perceptions of parental depression were found to fall into three categories: self-oriented perspectives (resistance and negativity), ambivalent perspectives, and, other-oriented perspectives (acceptance and compassion). Over time, respondents from the high-adversity families showed shifts from self-orientation to other-orientation, whereas the perspectives of respondents from low-adversity families remained unchanged. Some respondents with depression in both parents and/or siblings revealed changes in perception toward one parent but no change toward other family members with depression.

The relationship between mental health workers and family members

OBJECTIVE

To study the relationship between family members and mental health care workers to learn more about the support available to family members of mental health patients.

METHODS

Eighteen interviews were conducted with family members, seven with professionals and two with patients. Observations were performed at a long-term hospital ward and at family and client council meetings.

RESULTS

Family members perform an important carer role which greatly affects their lives. They need support from mental health professionals in order to cope. However, communication between mental health care workers and family members is problematic. Family members report a lack of information, consultation and support.

CONCLUSION

Family members and mental health care workers frame the role of family members in the care process differently.

PRACTICE IMPLICATIONS

Since the role of family members in the care process can be beneficial for all actors including the mental health patient it is important that mental health professionals acknowledge this and provide support to family members. Considering relatives as fellow carers (reframing their role) could be the way to do this.

Do nurses support the patient in his or her role as a parent in adult psychiatry? A survey of mental health nurses in Finland

This study describes the extent to which registered and practical mental health nurses support, and consider the support in the units on parental responsibility in adult psychiatry, with regard to clients who are parents of dependent children and the predictors for this. A questionnaire survey was carried out in 2005 with Finnish practical and registered mental health nurses. Most nurses claimed that they support the well-being of parent clients and discuss with them about their children. At the units there is offered a support for parents in the therapeutic milieu and with managing at home with their parental duties. Nurses' ability to support their clients as parents and to recognize the support at the units increases through personal experiences such as being parent, professional experience, and further professional education.

Are the children of the clients' visible or invisible for nurses in adult psychiatry?--a questionnaire survey

Children in families affected by mental illness are at an increased risk for developing psychopathology, emotional and behavioural problems. Nurses have direct and frequent contact with patients and their families, and are in a unique position to evaluate the situation of these children before problems arise. The aim of this study is to describe the interaction that practical mental health nurses (MHNs) and registered mental health currently have with children of their clients and predictors of this interaction when a parent is receiving psychiatric care. This is a cross-sectional study. In 2005, questionnaires were sent to all registered (n = 373) and practical MHNs (n = 235) working in 45 adult psychiatric inpatient and outpatient units in five Finnish university hospitals. The total response rate was 51%, while 60% (n = 222) of registered MHNs and 36% (n = 88) of practical MHNs responded. Most of the nurses did not meet children of their clients regularly, although they reported that information about children of the clients were gathered regularly at the units, and discussed clients' children with them. The personal characteristics of nurses, such as gender, age, marital status and being a parent, were significantly related to the nurse's propensity to pay attention to the children of their clients in adult psychiatry. Nurses' professional experience, further family education and use of family-centred care at the unit increased their interaction with the children of their patients. These results indicate that clients' children are not entirely invisible for most of the nurses in adult psychiatry. Knowledge of the risks faced by these children and implementation of the preventive approach should be included in the basic education of nurses.

Preventive child-focused family work: development of instrument in adult psychiatry

It is well-known that a parent's mental disorder has a significant psychosocial influence on the development of her or his children. This study reports the development process and psychometric testing of the preventive child-focused family work (PCF-FW) questionnaire in adult psychiatric settings. The PCF-FW instrument was developed to measure support for parenting, dependent children and family relationships in order to promote child development and mental health in adult psychiatry. A 133-item PCF-FW questionnaire was developed; the content validity, construct validity and reliability of the instrument were ensured by expert review, pilot test and internal consistency. The final instrument was distributed to all nurses (n= 608), including registered nurses (n= 373) and practical mental health nurses (n= 235), working in 45 adult psychiatric units in five university hospitals in Finland. Some 51% of all nurses responded. Correlation variables in each subscale varied between 0.1 and 0.8. Cronbach's alpha coefficients were 0.55-0.95 in each subscale, demonstrating the moderate to excellent internal consistency of the instrument. The Cronbach's alpha coefficient for the entire instrument was 0.94. In spite of some caveats, such as possible response biases, the present study suggests that the PCF-FW instrument is a valid and reliable tool for studying preventive child-focused family working in adult psychiatry.