Transcript Parental Mental Illness & Children’s Wellbeing

Think Child, Think Parent,
Think Family
Impact of parental vulnerability on children
Early and quickly is better
Dr Adrian Falkov
Senior Staff Specialist
Sydney West CAMHS
[email protected]
We Know…
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Multiple adversities & vulnerabilities –
demonstrated current, lifelong & generational
impact
Interplay genetic & psychosocial adversity,
vulnerability & resilience – Negative outcomes not
inevitable
Multiple (competing) needs (adult vs child; MH vs
Social care; CP vs family support)
Prevalence of MI & parenthood across all service
sectors & tiers
Parenthood amongst AMH & SMS (pts who are parents)
 MIPs of families known to children’s services
Comorbidity - MI, Substance Misuse & PD
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Major public health opportunity - implics for better
identification, intervention & prevention
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Family as NB target & mechanism for change
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Improving life chances & lived experiences for parents & children
If parents do better so will children
If children do better so will parents
Investment opportunity – early intervention,
economic benefits of promoting & enhancing
resilience
Neglect has life threatening consequences
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Stigma & discrimination – shame & isolation
Disruption to daily life – chaotic lifestyle, lack of routines,
parental hospitalisation
Developmentally inappropriate roles & responsibilities
(young carers)
poor parent-child interaction marked by parental disinterest,
hostility, less involvement and poor communication
Loss & feelings of confusion, uncertainty, fear &
anxiousness, anger & loyalty
Poor understanding about the meaning of parental actions
and concern about developing mental illness themselves
Greater risks of emotional & behavioural problems
fear of being removed from the family
Also…
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Tragedies (fatalities) highlight dangers of poor
communicatn & co-ordinatn between services
Systems failures & organisational malaise including
insufficient AND poor use of resources
Social capital, investment opportunities through
improving life chances & lived experiences for
parents & children
Effective treatment & rehab approaches
Management & leadership issues
And…
At some point in their lives, I believe, most human beings
desire to have children and desire also that their children
should grow up to be healthy, happy, & self reliant.
For those who succeed the rewards are great; but for those
who have children but fail to rear them to be healthy, happy
& self reliant the penalties in anxiety, frustration, friction &
perhaps shame or guilt, may be severe.
Engaging in parenthood therefore is playing for high stakes.
Furthermore, because successful parenting is a principle key to
the mental health of the next generation, we need to know
all we can both about its nature & about the manifold social
& psychological conditions that influence its development for
better or for worse
John Bowlby – Caring for Children
A Secure Base: Parent-Child Attachment & Healthy Human Development
The Family Genes
Recurrent, early onset Major Depression
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Onset depr in chhood – a single MDD assoc with nearly
50% chance of recurrence in future (Kovacs 96)
Chhood dysthymia – 78% chance of subsequent MDD
(Kovacs 96)
A parent or sib with MDD has 2-3 fold greater risk for depr
compared to gen popn risk (10%)
If the relative has severe, earlier onset (childhood / teens /
20s), recurrent MDD the risk becomes 4-5 X greater
About 50% of predisposition / heritability accounted for by
genes
Multi locus patterns of inheritance
Genetic vulnerability coupled to early adversity (abuse and
neglect), life events and loss imposes even greater levels of
risk
Gene environment interplay
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Caspi et al (03) longit study – 5-HTTLPR (serotonin
transporter gene-linked polymorphic region)
Number of life events predicted subsequent depression
according to number of short alleles at 5-HTTLPR position
Sim interaction for effect on depression of no of chhood
maltreatment indices between ages 3-11
Neither depr scores nor MDD predicted by genotype alone
It is the interplay between and cumulative effect of gene
environment influences
So…
What should it look like?
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Adults
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Children
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briefer, less frequent illness episodes
Reduced hosp, relapse
Improved cap to meet children’s neds
Harmonious relationships, social connections
Productive roles, educ & employment
Better self esteem, resilience
Improved cognitive, emotional, behavioural fning
Opportunities to achieve & have fun – ed attainment
Reduced stigma, shame, isolation
Harmonious relationships
Understanding parent’s illness
Families
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Cohesion, harmony happiness as a result of accessible flexible equitable
safe responsive services
Comprehensive service?
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Diagnostic
Severity
Population-based
All family members
Individuals v relationships
MH Promotion, prevention
A Vision For Change?
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Multiple, competing perspectives
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Across profession, team, service, agency
Working better together – everyone’s responsibility
Building AND Crossing Bridges
Shared understanding, role clarity & common
purpose – Of course, but HOW?
Role of mental health-illness for staff in ch’s services
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Prof awareness, knowledge, skills re MH of children & their
parents/carers
Impact of vuln ch on parents
Impact of vuln P on children
Identify, assess, intervene, evaluate
 Family focussed, developmentally informed
 Strengths-based, protection oriented
But…
Challenges and Dilemmas
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What does ‘think child parent family’ mean?
Dual diagnosis, Ingredients of complexity
‘Thinking’ v ‘Doing’ (Implementation)
How will we know? (Evaluation)
Information sharing v confidentiality
Support v protection, Vulnerability v resilience
Common experiences, competing needs
‘Must v should’
Resources - Service v science imperatives
Invisible Children
AMH Perspectives
‘You know, the thing is, the kids are important
but there’s always so much going on, so
much to do … that you, well, you go in with
good intentions but they’re so ill (pts), or
chaotic or needy or doing worrying things
that you, well, you kind of … I guess just
forget. I know I shouldn’t but that’s what
happens’
Children’s Understanding
Tom, Aged 7
‘Its not like a tummy ache or a cold - but
she's not feeling well. She thinks she's the
king, then I know something's wrong - in
the neck - where she speaks, (or maybe)
the heart - it's a very important part of the
body- makes you do things, or maybe the
mind - not the brain because the brain is
just to make you think & the illness is the
things she says…’
Young Carers - Liz Aged 11
When I was younger, mum had a problem. She had difficulty with us
4 kids - sorting us out for school - she wasn’t getting a lot of help
and she was shouting a lot. Her words were all jumbled up - didn’t
come out properly. She was having too many cups of tea... Always
asking me for cups of tea so i was late for school. I told the
teachers an excuse that mum overslept and I had to make breakfast
for the younger ones - mum didn’t want them to know she was sick
because she thought they were watching her and coming round
Liz went on to state that she thought it very unlikely anyone was
watching because “if there were watchers I’d have seen them - but I
didn’t tell mum this because she would have said how do you know
it’s unlikely?
Family mental health
More support, better connections
‘Mental illnesses are often accompanied by the
undefined burden that is borne by families of
affected individuals and the community in
terms of human and economic costs, as well
as the hidden burden of stigma and human
rights violations that may be encountered by
this vulnerable section of the community’
Commonwealth Department of Health and Aged Care, 2000
What does ‘Think Child Parent
Family’ Mean?
"When I use a word", Humpty Dumpty said, in a
rather scornful tone, "it means what I choose it to
mean, neither more nor less“
"The question is," said Alice, "whether you can
make words mean so many different things"
Lewis Carroll
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Definition – ‘normal’ vs ‘abnormal’ / vulnerable
Who? which individuals; which families
Social exclusion; state intrusion vs neglect
Stigma
Happy families – key ingredients??
Parenting
Enduring x gen vs prevention
DV
Dual diagnosis?
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Mental Illness & Substance Abuse
Mental Illness & Domestic Violence
MI in parent AND child
MISA in BOTH parents
Axis I AND II (psychosis & PD)
Depression/anxiety, alcohol abuse & PD
Ingredients of Complexity
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Quadruple diagnosis
Diagnostic uncertainty
Too much, too little, poor quality info – difficulties
across multiple domains
1 person, multiple difficulties
1 or more difficulties in > 1 person, concurrently,
at different times
Early adversity, resilience & susceptibility
Staff education, training & experience
Multiple services & agencies
‘Must v Should’
Policies, frameworks, strategies and guidelines
While there is no general legal impediment to using
the directive (ie ‘must’) rather than the suggestive
(ie ‘should’) in the Policy, 2 factors should be kept in
mind:
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Is it necessary to mandate (ie use the word ‘must’) that all employees
in all circumstances behave in an exact manner; and
As a breach of the Policy may result in a breach of the … code of
conduct , the use of the directive should be limited to circumstances
where an employees compliance with the Policy is not dependent on
factors outside the employees control;
Should: ‘an action that should be followed unless
there are sound reasons for taking a different
course of action’
Resources – caught between
service & science imperatives
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Much increased awareness & successes in carer
& consumer involvement, dev of materials for
families & professionals
No clearly articulated, well evaluated models
(Bendigo grp Fraser et al review of intervention
programmes targeting ch wellbeing – 26/520
papers only 7 methodologically strong). See
SCIE review
Need evidence to argue for resources
Need resources to generate evidence
From ‘Thinking’ to ‘Doing’
Implementation
‘Most things out there are designed to stop you
making a difference. All the biggest bets in
life are on the status quo. Plenty of people
think they would like to change things but
lack the energy or the imagination to clamber
over, or beat a path through, the status quo…
only the few determined and inspired ones
will make a real difference.’
Paul Keating – the power of the status quo - Occasional address – UNSW, 15 April
2003
How Will We Know?
Evaluation
'Here is Edward Bear, coming downstairs now
bump, bump, bump, on the back of his head,
behind Christopher Robin.
It is, as far as he knows, the only way of coming
downstairs, but sometimes he feels that there
really is another way, if only he could stop
bumping for a moment and think of it.
And then he feels that perhaps there isn't'
A. A. Milne, Winnie the Pooh
Competing needs
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Interplay between multiple psychosocial
vulnerabilities & socioeconomic
disadvantage over the lifespan and across
generations
Dual diagnosis is the norm for Statefunded, public sector services
Strategies, tactics and
approaches
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SCIE Guidelines – comprehensive approaches
Conceptual frameworks & learning materials
Identification, assessment & intervention
Family intervention
Parenting is a mental health issue
Working better together
Evaluation
Political will, advocacy and tragedy (policies,
resources and leadership)
Stigma
SCIE Guidelines
Comprehensive approaches
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Systematic service level identification & recording
of children, parents, families
Appropriately tailored assm of need by relevant
sectors of a competent, confident & visible
workforce
Capacity (skills, resources) to support & intervene
according to assessed need utilising evidence
based interventions, early & quickly
Evaluation & research (tailored & specific
modifications of existing interventions &
approaches)
Conceptual Models
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Continuum of need
Family Model – Crossing Bridges
Family Focussed Assessment
Crossing Bridges
Key Principles
1.
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4.
The MH & wellbeing of children & adults within
families in which an adult carer is mentally ill, are
intimately linked in at least 4 ways:
PMI can adversely affect the development and in some
cases the safety of children
Growing up with a MIP can have a negative influence on
the quality of that person’s adjustment in adulthood,
including their transition to parenthood
Children, particularly those with emotional, behavioural or
chronic physical difficulties, can precipitate or exacerbate
mental ill health in their parents/carers
Adverse circumstances (pov, single p, social isoln, stigma)
can negatively influence both child & parental MH
Crossing Bridges
The Family Model
4 Stressors & vulnerabilities
1
Adult
mental
health
3
Parental &
fam relationships
2
Child dev
& mental
health
4 Strengths, resilience & resources
Identification
Every Family in the Land?
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Epidemiological studies highlight widespread
prevalence and complex interplay between MISA,
childcare burden and social adversity
Given the number of MISA adults of child bearing
and rearing age there are substantial public health
implics for better detection, intervention and
prevention
Surveys highlight relevance of considering childcare
and protection issues amongst MISA services and
dev of MISA perspective amongst all children’s
services
Assessment – Key Areas
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Who to assess
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What to assess – key domains
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The child
The ill parent
Partners & other key people in the child’s life
Parenting
MI &/or SA in parent (MS; risk harm to self/other; diagnosis; Rx;
Prognosis; service/need match – availability of resources; broader social
needs)
Safety, wellbeing & health of children
How to assess
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Talking with children whose parents are MI or abusing substances
Talking with parents / carers who are / may be MI
FaMHliS
Talking Together
Child psychiatrist:
‘Do you worry you might upset your children if you
talk to them about your difficulties?’
Adult psychiatrist:
‘Do you worry you might upset yourself?’
Family intervention
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Early (age – eg children)
Quickly (stage – of illness)
Identify, assess, intervene, review
Family as key target for early intervention
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+ve impact on children reduces burden for
parents
+ve impact on parents promotes children's
wellbeing and safety
Heide Lloyd, Mother of Hannah &
Georgina
‘I did not realise how depressed I was at the
time & now looking back I feel quite shocked
to think that I coped with a new baby & a
toddler, having just given birth, & believing
that I could be living in a world where I
thought I could hear & even see people who
were not there. This eventually subsided over
about 5 months, though I had felt unable to
share the experience with anyone, sensing
disbelief & feeling really afraid that I would be
locked up & my children taken away’
Parenting is a Mental Health Issue
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Pivotal role in attachment, development & positive
mental health
Mediator of good experiences, a buffer vs adversity
& NB determinant of successful transition to
parenthood
A potent source of adversity – poor quality
relationships:
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Direct effects of abuse & neglect
Absence of sufficient protection against life events & losses
Early trauma & later susceptibility to MISA & poor adjustment
Mechanism for transmission of adversity
Working Better Together
professional perspectives
I was scared. That’s the simple truth of it. Scared.
Terrified. She (mother) was in the corner but he
(father) was standing up. Shouting. I could see
his veins pulsing. Like he was going to explode.
He didn’t want to come into hospital. Said his wife
couldn’t manage the children. He was usually so
calm I was shocked at the change. It took a long
time to get over that. Oh of course I did all the
usual stuff – trying to be calm, talking him down,
pressing the security alarm. But I was still not
prepared when it happened. Took me a long time
to get over it
Working better together
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Thinking family when talking with individuals
Supporting adults whilst ensuring the wellbeing &
safety of children
Better identification and recording of vulnerable
children, assessment of their needs and interventn
according to assessed need
Improving children’s & parents understanding of
and communication about MI (& SA)
Identifying strengths
Working better together
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Integration of research into practice
Making prevention / EI part of mainstream
practice
Availability of learning opportunities
Workforce enhancements
Local integration of teams and services
Cross agency partnerships & protocols
Tackling stigma
Resources – best use of and credible argument
for additional
Evaluation
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Of what?
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Family: Children; MIP; Partner;
Services: frontline staff; managers; teams; services;
agencies
Intervention: treatment, protection, support,
prevention, protocols
Implementation actions targets / benchmarks /
standards
Workforce knowledge attitude skill recruitment retention
Involve family members - how will we know
outcomes are improving
Generate good arguments for resources and
investment
Tackling Stigma & Discrimination
“The subject first caught my attention twenty years
ago when I came across a table of charitable
giving showing cancer close to the top and mental
health near the bottom. I wondered why care of
the mind should rank so much lower than care of
the body. The position is the same today. The
cancer charities are followed closely by the animal
charities. We give more to dogs than to those with
mental problems.”
Jeremy Laurance
‘How fear drives the mental health system.’
Children’s understanding of parental
psychiatric disorder
Improving outcomes for families
How can children understand what
parents can’t explain?
Sam, Aged 10, about his Father’s
Schizophrenia
Schizophrenia problems are to do with your
health, your head, stress and laziness and
anger. Depression is when you feel lonely
like nobody cares.
When I was very young Dad was saying in
100 years the world will destroy itself.
There will be mayhem and death and things
like that. I think that I was about five. It
made me very worried.
Children’s Understanding
During a meeting with his family, Jumai, a 7 yr
old described a conversation with his father:
‘We were talking about her and dad said about
the controller - you know, for the TV. If you
press all the buttons all the time very quickly
and it jumps about all over - going crazy that’s like what was happening in Mum’s
head. She was in hospital.’
Crossing Bridges
Prevention
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Reduce child exposure to parental symptoms
Assertively treat parental illness
Promote positive parenting
Reduce exposure to parental discord
Educate parents about MISA
Educate children about MISA & ways of coping
Promote open discussion about MISA in families
Facilitate support outside the home
Promote opportunities for relationships &
achievements within school
Address socio-economic factors
Conclusions
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Not possible to separate protection of children
from wider support to families, especially when MI
&/or Substance misuse present
Support for children & families cannot be achieved
by a single agency alone
Children are vulnerable & unsafe if staff in different
agencies do not fulfill their separate & distinctive
responsibilities
Combination of service structures that support staff
together with awareness, knowledge & skills
Effective management & leadership
Conclusions
Improve identification, assessment and
intervention:
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A broader, inclusive approach: MH & social
care, Child & adult (parent), CP & Family
support
A lifespan and cross-generational perspective
Working together and crossing bridges
Talking with children and parents (family
approaches)
Conclusions
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Provide targeted training & ongoing
education
Develop service level partnerships within &
between agencies
Prevention & early intervention - children's
services as an explicit preventive component
of adult services?
Conclusions
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Use Media opportunities
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Use evidence on prevalence of parenthood &
impact on children to
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Promote positive mental health & tackle stigma
make best use of existing resources
argue coherently for additional investment
improve clinical practice (assessment of need & early
intervention)
Dev evidence base - models of good practice