Transcript Presentation: Parental Mental Illness

PARENTAL MENTAL HEALTH PROBLEMS
AND THE EFFECTS ON CHILDREN
AIMS
You will be able to:
• Briefly describe the main adult mental health problems and the
pathways through which problems may be transmitted within
parent child relationships
• Identify specific risk factors relating to children with a parent
with a mental health problem
• Describe adaptive strategies and resultant behaviours in
children
• Practice talking with children about mental illness/substance
misuse
• Consider the implications of the above for your practice
DEFINITIONS AND CLASSIFICATION
MENTAL DISORDER OR HEALTH PROBLEM?
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“…the existence of a clinically recognisable set
of symptoms or behaviour associated in most
cases with distress and interference with
personal function.” WHO
Mental health problems are more transient,
less definable and common, but will impact on
personal functioning
ICD 10
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Mood Disorders
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Mania
Bipolar affective disorder
Depression
Schizophrenia
Organic Disorders
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Alzheimers
Dementia associated with other diseases
ICD 10
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Substance Misuse Disorders
Behavioural Syndromes
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Developmental disorders
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Eating disorders
Sexual dysfunction
ASD
Behavioural/emotional disorders
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ADHD
Conduct Disorder
Tics
ICD 10
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Neuroses
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Disorders of adult personality
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Phobias
Obsessive compulsive disorders
PTSD
Personality disorders
Learning disabilities
DEPRESSION
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Reactive depression
Endogenous depression
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Four areas affected
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Mood – misery
Cognition-reduce concentration/self esteem
Physical – poor sleep, diurnal variation & poor appetite
Accumulative interactive impact – guilt, helplessness,
lack of future, ideas about death/suicide
DEPRESSION
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Key symptoms:
 Misery
 Diurnal
variation
 Poor appetite
 Lowered self esteem
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Severe depression include the above plus 3 or
4 of the others
Severe depression with psychosis – all ten
symptoms plus delusional states
MANIA
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Mood – positive to ecstatic
Cognition – speeding of thoughts and speech
Physical symptoms – never tires, agitated
Accumulative interactive impact – ecstatic
expansion of self
Can be associated with psychotic symptoms
BIPOLAR DISORDER
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Repeated phases of mania followed by
depression usually with recovery in between
SCHIZOPHRENIAS
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Disordered thoughts
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Perception and affect disturbed
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Not in control, stuporised
Disorder of senses
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Incongruity of mood
Disorder of volition
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Speeded up thoughts or thoughts blocked
Intrusive or broadcasted thoughts
Hallucinations
Primary delusions
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False beliefs (time and culturally influenced)
Can be paranoid
PERSONALITY DISORDERS
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Paranoid – other people are interpreted as
demeaning or threatening
Schizoid – indifference to social
relationships/ restricted range of emotional
experience and expression
Anti Social – callous unconcern for others or
social norms
Emotionally unstable – impulsive with
affective instability
RISK
Biological
Genetic loading
In-utero exposure
to toxins
Stress
RISK
Psychological
Insecure attachments
Learned negative cognitive
distortions
Parentification
Negative attributions
Chronic trauma
Social
Poverty
Stigma
Reduced educational role
Impaired social interactions
-poor self esteem
-parents not promoting
social adaptations
TRANSMISSION PATHWAYS
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What gives rise to
the risk of parental
mental health
problems also create
risks to the parentchild relationship
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E.g. Long standing
attachment problems
likely to lead to
increased risk of adult
depression and
impact on the
effectiveness of
parenting
TRANSMISSION PATHWAYS
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What gives rise to
the risk of parental
mental health
problems also create
risks to the parentchild relationship
PLUS
The parental mental
health problem also
increases risk
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Insensitive parenting
arising from risks to
the parental mental
health problems is
further worsened by
the mental health
problem
TRANSMISSION PATHWAYS
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Mental health
problem alone
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E.g. Lack of affect is
disturbing to a child.
PARENTING AND THE
IMPACT ON PARENTING
BEING A PARENT DEPENDS ON ...
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Our personality and temperament
Whether we have the support of a partner
Whether we have the support of family and friends
How many children we have and what ages and developmental stages they
are at
Whether our children are physically and mentally healthy or whether they
are coping with significant health or developmental problems
Whether we are combining child care with the demands of paid employment
Whether we have enough money to bring up our family or are finding it hard
to make ends meet
Whether we live in comfortable housing or are struggling with poor
accommodation
Whether we are coping with stressful events in our lives such as a
separation, a bereavement or unemployment
The experiences we had in our own childhood, and whether or not we have
been able to come to terms with any problems that we faced when we were
young
Youngminds (2004) Looking After Ourselves
NEGATIVE EMOTIONS GENERATED THROUGH
BEING A PARENT
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Anger
Resentment
Exhaustion
Envy
Boredom
Guilt
Sadness
Disappointment
Despair
Youngminds (2004) Looking After Ourselves
PROBLEMS IN PARENTING
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Physical exhaustion
Feeling tearful
Feeling depressed
Feeling agitated
Feeling angry more often
than is usual for you
Difficulty sleeping
Mood swings
Feelings of panic
Difficulty concentrating
Youngminds (2004) Looking
After Ourselves
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Difficulty making decisions
Losing interest in life
Avoiding other people
Negative thoughts
Suicidal thoughts
Not eating or over-eating
Smoking or drinking more
than is usual for you
IMPACT ON PARENTING
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Parental mental health problems are highly
correlated with poverty and deprivation, poor
housing and social adversity.
For some the stigma of mental health problems
and racism further exacerbate risk to children
IMPACT ON PARENTING
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Attachment relationships
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Communication
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Combination of discord and mental health problems is very dangerous
to children
Separation and Change
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Children need information
Adult Conflict
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Emotionally attuned engagement
Children fear parental separation. Also fear being removed from the
family and fear parents admission to hospital
Peer Friendships and Support
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Friendships change for the worse
IMPACT ON PARENTING
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Parental Behaviour
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Children’s behaviour
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Most parents with mental health problems do not pose a
risk to children. For those that do they are more likely to
have been psychotic, co-morbid and socially deprived.
Some evidence that the severity of parental mental health
problems increases likelihood of children’s behaviour
problems
Coping
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Non productive coping styles/avoidance in parents are
adopted by children
IMPACT ON PARENTING
Parents may
• be unable to ensure the basic (physical) care and safety of
children
• readily attend to a child’s physical needs (such as maintaining
a ‘spotless home environment’) but struggle with the provision
of warmth and praise
• not appreciate their child as an autonomous individual with his
or her own separate, age-dependent needs
• expect their child to behave as an adult and to undertake a
variety of adult tasks and responsibilities (for example, role
reversal with developmentally inappropriate expectations)
IMPACT ON PARENTING
Parents may
• be unable to play with and provide adequate
stimulation for their child
• struggle to provide appropriate guidance, boundaries
and necessary stability for their children
• become frustrated when efforts to discipline their
children are unsuccessful (escalating cycles of
coercive exchange have been well described; criticism
and hostile responses may occur and physical
punishments ensue, which may in turn result in
physical harm)
• be unaware of the nature and extent of their children’s
emotional needs.
SPECIFIC RISK FACTORS
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Persistent negative views expressed about a child,
including rejection
Ongoing emotional unavailability, unresponsiveness
and neglect, including lack of praise and
encouragement, lack of comfort and love and lack of
age appropriate stimulation
An inability to recognise a child’s needs and to
maintain appropriate parent child boundaries
Ongoing use of a child to meet a parent’s own needs
SPECIFIC RISK FACTORS
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Distorted, confusing or misleading communications
with a child including;
involvement of the child in the parent’s symptoms or
abnormal thinking, including, for example, delusions
targeting the child
incorporation of the child into a parent’s obsessional
cleaning/contamination rituals, or keeping a child at
home because of excessive parental anxiety or
agoraphobia
Ongoing hostility, irritability and criticism of the child
Inconsistent and/or inappropriate expectations of the
child.
ATTACHMENT AND CHILD DEVELOPMENT
ATTACHMENT THEORY
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Attachment behaviour is defined as
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the seeking of protection when anxious which is
triggered by external threats or behaviours.
The person to whom a child is attached
provides a secure base, a place of safety,
warmth and comfort.
ATTACHMENT THEORY
A securely attached child feels confident that should
they feel anxious, their parents will respond. Such
security is brought on by interactions which are
 sensitivity
 regularly available and reliable
 warm
 responsive, and
 consistent
WAY ATTACHMENT DEVELOPS
need
tru st
re la xa tio n
se cu rity
a tta ch m e n t
sa tisfy
need
a ro u sa l - re la xa tio n cycle
h ig h
a ro u sa l
INSECURE AVOIDANT ATTACHMENTS
 Children
who anxiously avoid contact have
been rejected.
 This avoidant attachment behaviour is a way
of coping with distress.
 The distress itself is turned inwards and the
view of self which emerges is an unworthy
one.
 Adults are experienced as unavailable,
untrustworthy and rejecting.
REPRESENTATIONAL MODEL (AVOIDANT)
 Caregiver
subtly or overtly reject child’s attachment
needs at time of stress
 Bids for comfort will be rebuffed
 Child keeps his/her attention directed away from
their caregivers in an effort not to arouse anxiety
and frustration
 In control because of the need for self reliance
 Comfort self rather than accept it from others
REPRESENTATIONAL MODEL (AVOIDANT)
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The infant cannot approach because of the
parent’s rejection and cannot withdraw
because of its own attachment needs. Rebuff
heightens alarm and hence heightens
attachment, leading to increased rebuff. By
repelling the infant the mother simultaneously
attracts him.
INSECURE AMBIVALENT ATTACHMENTS
 Children
who show an ambivalence in their
attachments have experienced inconsistent or
chaotic care.
 Their attachment behaviour is intensified to
attract the parent.
 Relationship meets mother’s needs rather than
those of the infant
 Such children are often angry and resent their
carers.
REPRESENTATIONAL MODEL (AMBIVALENT)
 Caregiver
will be inadequate at meeting child
attachment needs (caregiver is passive,
unresponsive and ineffective)
 Child’s strategy is to amplify attachment needs and
signals in an effort to arouse a response (verbal
and behavioural: bubbly affection to rage, anger,
panic and despair. All experienced as controlling)
 Unlovable and helpless selves & unpredictable and
withholding others.
ANTECEDENTS OF DISORGANISED
ATTACHMENT
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The antecedents of this behaviour can be:
The secure base has not been available so attachment
behaviour has failed to achieve its goal of proximity to the
secure base
 Prolonged separation in adverse conditions
 Strong rejection by the parent with threats to send the child
away
 Depression, alcohol and/or drug misuse
 Intense marital conflict
 Actual abuse, physical, emotional, sexual
 Absence of reparation
 Abdication of care giving
At the core of this experience is a frightening or frightened
attachment figure
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DISORGANISED ATTACHMENT
 Care
givers are both unpredictable and
rejecting
 Child finds it difficult to organise attachment
behaviour to increase care and safety when
the care giver is the source of distress
 Children feel vulnerable and out of control;
they become listless or coercive
CHARACTERISTICS OF DISORGANISED
ATTACHMENT
 Absence
of a secure base and unrelieved anxiety
 Mistrust of adult authority
 Hyper-vigilance
 Sensitivity to denigration and humiliation
 Need to be in control to cope with helplessness in
the face of overwhelming and uncontained
anxiety in the presence of adults who may be
frightening and unreliable
REPRESENTATIONAL MODEL (DISORGANIZED)
 Child
experiences the carer giver as ‘the source
of alarm and its only solution’.
 Child in these circumstances is unable to be
guided by their mental model of the world
because it offers few directions.
 Frightened, helpless, fragile and sad
 At risk of mental health problems or anti-social
behaviour
EFFECTS ON THE CHILD
Implications for attachment styles (meta analyses)
 Martins
and Gaffan (2000) found a reduced
likelihood of secure attachments, increased
likelihood of avoidant & disorganised styles in
children of depressed mothers.
 Atkinson, et al (2000) found a link between
maternal social/marital support, maternal stress
and maternal depression and attachment security
EFFECTS ON THE CHILD
Implications for attachment styles (single studies)
 Teti et al (1995) found that maternal depression is linked to
an increase in attachment insecurity. Those children with
disorganised styles were more likely to have chronically
impaired mothers
 Bifulco et al (2002) studied 276 mother-offspring pairs half
of which were vulnerable in terms of interpersonal
functioning and low self esteem. Offspring of vulnerable
group 4x more likely to be psychiatrically disordered and 2x
more likely to experience severe neglect, physical or sexual
abuse before age 17. Vulnerability and not maternal
depression accounted for these differences.
EFFECTS ON THE CHILD
Implications for attachment styles (single
studies)
 Walsh
et al (2009) found differences in
coping strategies for middle aged children of
mother with a mental health problem.
WALSH ET AL’S STUDY
Multiple strategies following social conventions
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[It’s the boy/girl’s first day and s/he is saying goodbye to Mum
at the school gate…how would you feel in this situation?] Same
as he probably would [scared and excited? These were
generated in response to an earlier question] Yeah. [Why?] Well
because it would be a new school and I would have to make
new friends and some people might take the mick or
something, but, um, I’d look forward to it because it would be a
new experience. I’d be looking forward to making new friends
with teachers and things, new work and things. [What would
you do?] Do what I was told to do by the teacher, do what I’m
supposed to do, what everyone else was doing…try to chat to
some people there and chat to the teachers and things…
WALSH ET AL’S STUDY
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Little adaptive coping strategy
[It’s the boy/girls’s first day and s/he is saying
goodbye to Mum at the school gate…how would you
feel?] A bit upset ‘cause a new school would be a bit
scary [What would you do?] Uh, can’t think of
anything. [What might you do?] Sit down
EFFECTS ON THE CHILD
Lynne Murray’s longitudinal work
 Women
with post natal depression often had
further occurrences of depression later in life
 Analysis of total months of maternal depression
predicted offspring depression p = 0.008
 Total months of maternal depression a more
significant predictor of children’s depression
(p=0.018) than post natal depression status
(p=0.11)
TRAUMATIC STRESS
The automatic response to trauma, involving the
production of toxic amounts of stress hormones which
affect:
Brain
All
function
major body systems
Social
functioning
IMPACT OF TRAUMA/STRESS
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The ultimate endpoint of experiencing
catastrophic states of relational-induced
trauma in early life is a progressive impairment
of the ability to adjust, take defensive action, or
act on one’s own behalf, and, most importantly,
a blocking of the capacity to register affect and
pain.
Schore, A (2001) The effects of early relational trauma on right brain development,
affect regulation and infant mental health. Infant Mental Health Journal 22(1-2),
201-69
IMPLICATIONS FOR PRACTICE
ADAPTIVE STRATEGIES
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Helpless and preoccupied parent – child likely
to be attention-seeking. If these provoke a
response then the attention-seeking is
adaptive.
Ambivalent styles
Parent likely to make inaccurately minded
comments
ADAPTIVE STRATEGIES
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Irritable and hostile parents- present children
with difficulties in adapting. The inadequate
source of comfort is also the cause of alarm.
Disorganised styles of punitive controlling and
compulsive self reliance
ADAPTIVE STRATEGIES
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Helpless parents who are consumed by their
own despair – children adapt by taking control
of the relationship by being attentive and
solicitous.
Avoidant style helps with feeling insecure but
child struggles to understand own emotions.
Parent like to make few minded comments.
Child may display moody behaviour outside the
home.
RESILIENCE
Compensatory
Challenge
Protection
Change child’s appraisal and cognitive processing of
events
Reduce exposure to risk
IMPLICATIONS
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Effects are mediated by the interaction between the
biological, psychological and social.
The ‘mind’ is constructed through a combination of
genetics, constitution and the environment.
More specifically one’s identity is formed through
interactions with other people’s minds (subjective
states), typically parents.
The mind is made up of thoughts, feelings,
perceptions, memories, interpretations and beliefs
and these mediate the way the other person is
experienced and reacted to.
IMPLICATIONS
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Parental behaviour is likely to be influenced by
how the child is perceived, evaluated and
integrated into the parent’s mind which will be
influenced by both current and previous
experiences
PRACTICE
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Preoccupation with the states of children and
parents’ minds and the interaction between
these.
Interagency practice which elevates mindful
discussion.
Acceptance that there are other ‘psychological
views’.
Organisations which are minded.
Adaptable responses