doc daimler only

April 2011 Vol. 27, No. 4 • ISSN 1058-1073

Online ISSN 1556-7575

Highlights… Dr. G. Oana Costea discusses the

complex relationship between a child and a parent with mental illness.

Drs. Robin Everhart and Daphne Koinis- Mitchell examine ways to help parents care for a child with asthma, including a family- focused project targeting Latina women.

✦ ✦ ✦

Keep Your Eye On… See page 2 •  RCT of melatonin for sleep problems in autism •  Strep infections and exacerbations

in tic and OCD symptoms •  Obesity program targets ethnically

diverse population

What’s New in Research… See pages 3–4 •  Restricted elimination diet in children

with ADHD •  Pediatrician experiences in collaborating

with child psychiatrists

Editor's Commentary •  Misguided gun legislation would make

children less safe — By Gregory K. Fritz, M.D. See page 8

✦ ✦ ✦

Free Parent Handout…

Are you concerned that you or your child has asthma?

Parental Mental Illness

Considering the children of parents with mental illness: Impact on behavioral and social functioning By G. Oana Costea, M.D.

In the context of increased availabil- ity of community-based mental health treatment, rehabilitation programs, and advances in psychopharmacology, more patients with serious mental illness are now parents, many with young children. Consequently, there has been increased attention toward the potential impact on children of parental mental illness.

National Comorbidity Survey data indi- cate that about 31% of American women and about 17% of men have a 12-month prevalence of at least one psychiatric dis- order (not including substance abuse), and of those 65% are mothers and 52% are fathers. The literature supports the asso- ciation between parental mental illness and

adverse pediatric outcomes in terms of cognitive, emotional, social, and behavioral functioning. The rates of psychiatric diag- nosis among children of parents with men- tal illness were shown to be 30–50%, com- pared to an estimated rate of 20% among the general child population. The risk is even greater if both parents are mentally ill.

The parenting experience Research suggests that for many par-

ents with mental illness, their relation- ships with their children are a source of great personal satisfaction and fulfillment, which can enhance their confidence and parenting motivation. However, a study

Caregiver Quality of Life

Supporting caregivers in the management of childhood asthma By Robin S. Everhart, Ph.D., & Daphne Koinis-Mitchell, Ph.D.

Approximately 8 million children in the United States have asthma (NHLBI, 2007), with children from racial and ethnic minor- ities at greater risk for asthma prevalence and morbidity. It’s well understood that children with asthma are at an increased risk for experiencing emotional, social, and behavioral difficulties. They may experi- ence emotional distress due to their asthma symptoms (e.g., shortness of breath, chest tightness), or due to the limitations imposed by their disease (e.g., not being able to keep up with others during recess).

But what about the emotional dif- ficulties of the parent? Parents or other caregivers must assume the lion’s share of responsibility in the day-to-day manage- ment of the child’s asthma, in addition to the demands of the rest of their family. It is up to them to ensure that medications are taken daily, prescriptions are refilled on time, and daily asthma triggers are avoided. Such responsibility has the potential to add significant stress and feel burden- some, which can affect the psychological

Monthly reports on the problems of children and adolescents growing up

See Asthma, page 6…

Published in cooperation with Bradley Hospital

See Parents, page 5…

View this newsletter online at wileyonlinelibrary.com • DOI:  10.1002/cbl.20137

The Brown University Child and Adolescent Behavior Letter April 2011

5

Continued on next page…

Parents From page 1

involving Japanese mothers with chronic mental illness found that some mothers reported “feeling sorry” for their children, with the potential for bringing anxiety into the parent-child relationship.

Parents’ perception of their children’s attitudes toward their illness must affect their parenting practices. While anxiety about being hated or rejected can lead to greater psychological burden, feeling a child’s compassion may result in feelings of fulfillment and strength.

Parents worry about the impact of their mental illness on their children, which can lead to unrealistic expectations of children’s development and behavior, or a tendency to see children’s behavior as pathological. In that context, they may feel responsible or blamed for their children’s problems. These parents may also interpret their own very normal struggles as a parent as an illness-related personal deficit, rather than the realities of being a parent.

It is well known that parents benefit from a sense of community, and the stigma of mental illness may lead to social isola- tion. Additionally, parents with mental ill- ness are more likely to be living without a partner. And while family members may be a primary source of support, they can also be a source of added stress.

Impact on child outcomes Twin and adoption studies support the

role of genetics in transmission of mental illness from parent to child. In addition to genetics, research suggests a multitude of protective and risk factors that influence the impact of parental mental illness on chil- dren, including biological, illness-related, environmental, and child-related factors.

Biological factors: Infants of moth- ers with schizophrenia have been found to face a higher risk for low birth weight, premature delivery, and fetal or neo- natal death. Maternal depression could contribute to a higher risk of delivery complications, lower Apgar scores, and lower tonus. Research has shown addi- tional neurobiological effects of maternal depression, including alterations in fron- tal lobe activity of preschool-age children that correlate with diminished empathy and behavioral problems.

Further, higher serum cortisol concen- trations were found in children of mothers with depression, which correlated with the mother’s severity of illness. And finally, a mother’s health behaviors and prenatal care could be affected by the mental ill- ness, with subsequent impact on preg- nancy and fetal development.

Illness-related factors: A range of fac- tors appear to be closely related to child outcomes in terms of enhancing resilience or risk: a) severity of symptoms and chronic- ity of illness; b) compliance with treatment; c) parents’ adaptive functioning; d) level of parental awareness of the illness and insight into the effects on self and children.

ADHD Parental ADHD appears to be associ-

ated with higher levels of family conflict, and offspring without ADHD in those families showed poorer school performance.

Bipolar disorder Research suggests that the offspring of

bipolar parents have elevated levels of mood disorders (5%–67%), increased rates of other psychopathology (particularly attentional and behavioral problems; 5%–52%), and greater academic difficulties.

Depression Parental Major Depressive Disorder

(MDD) was associated with increased risk of MDD in offspring, as well as greater likelihood of anxiety disorder and alcohol dependence. Having a father with MDD may increase a child’s risk for conduct disorder, while having a mother with MDD increases the risk for substance misuse.

Schizophrenia Children of parents with schizophrenia

are at increased risk of developing the dis- order given a suggested heritability of 75%. Data show that the risk of developing the illness was reduced in families with good parental relationships.

Substance misuse Children of substance misusers show

elevated rates of psychopathology and dif-

ficulties in academic, social, and family functioning. Offspring of fathers with both substance dependence and antisocial per- sonality disorder tend to have significantly more abnormal scores on the Child Behav- iour Checklist and may be more likely to have a deviant peer group.

Environmental factors Parenting behavior: Research suggests

that mental illness affects parenting behav- ior, which subsequently has a strong influ- ence on child outcomes. For example, moth- ers with schizophrenia show decreased ver- bal and emotional responsiveness, includ- ing less anger, compared to well parents. Mothers with depression, on the other hand, express greater levels of negative emotions (i.e., hostility, irritability, sadness). These parenting attributes are risk factors that may be associated with disrupted attachment and developmental delays in language, attention, and social competence in infants and toddlers. The quality of the mother- child interaction seems to be a stronger predictor of disrupted attachment than the parental depression itself.

The child portion of the Sequenced Treatment Alternatives to Relieve Depres- sion (STAR*D) study, a large multisite effec- tiveness study, showed that successful psy- chopharmacological 3-month treatment of depression in mothers to remission was associated with reduced psychopathology in children. Children who were asymptom- atic at the initiation of treatment were sig- nificantly more likely to develop symptoms if their mothers did not remit during the treatment period.

Marital or partner relationship and family functioning: Marital discord and divorce are more common in families where a parent has a mental illness, and such dis- cord may be a stronger predictor of child problems than even the mental illness itself. On the other hand, the presence of one sup- portive spouse or partner can have a positive impact on child outcomes.

Even without marital discord per se, households with a parent with mental ill- ness are prone to be more chaotic envi- ronments, with lower family cohesion, increased parent-child discord, and poor communication. Not surprisingly, such an environment has a negative impact on children’s emotional and behavioral func- tioning, including higher rates of offspring

Research suggests that mental illness affects parenting behavior, which subsequently has a strong influence on child outcomes.

The Brown University Child and Adolescent Behavior Letter April 2011

6

Continued from previous page... depression, substance misuse, and conduct disorders.

Factors such as poverty, less education, single parenthood, young parenthood, and social isolation are also found to increase vulnerability for adverse outcomes in chil- dren of parents with mental illness.

Child-related factors A child’s personality or characteristics

can influence the parents’ symptoms and behavior, which in turn affects children’s outcomes. For example, a child’s difficult temperament (defined as irregular in feed- ing and sleeping patterns, poor adapt- ability, negative mood, and intense reac- tions) can significantly challenge parenting abilities, leading to a higher likelihood of behavioral problems in childhood.

While research is inconsistent regarding whether boys or girls are more adversely affected by parent mental illness, studies suggest that girls are more likely to develop depression and boys, conduct problems. Younger age at the onset of parental illness is associated with increased vulnerability.

Child factors that promote resilience and serve as protective factors include: greater intelligence, positive self-esteem, good physical health and positive body image, strong interpersonal skills, posi- tive peer relationships, good problem-

and current trauma, and family and marital relationships.

Child-focused interventions: The litera- ture notes that children often report feeling ignored by professionals, as they are not given information about their parents’ ill- ness and its impact on the family. Children are often ashamed of their parents’ mental illness, sometimes living with the mixed emotions of loyalty and concern, while feel- ing guilty about their own feelings of resent- ment. Add to this their perceptions that their parent is stigmatized by others.

Therapeutic and supportive interventions include: a) age appropriate psychoeducation regarding parents’ illness; b) provision of information and access to services pertain- ing to parent hospitalization and respite; and c) individual therapy and support.

✦ ✦ ✦

G. Oana Costea, M.D., is Clinical Assistant Profes- sor of Psychiatry and Human Behavior at Brown Medical School and Director of the Children's Inpatient Program at Bradley Hospital.

References Nicholson J, et al.: Critical issues for parents with mental illness and their families. Center for Men- tal Health Services Research, University of Mas- sachusetts Medical School.

Leverton T: Parental psychiatric illness: The impli- cations for children. Current Opinion in Psychiatry 2003; 16:395–402.

solving skills, interest/success in school, and healthy interests outside the home. An understanding that the parent is ill (and therefore that the child is not to blame) can help a child view the situation realistically while building resources for support. Of course, having a sense of being loved by the ill parent, as well as stable and support- ive relationships with other healthy adults, can enhance children’s ability to cope.

Therapeutic interventions Paying attention to and soliciting the input

of the children, and addressing the needs of both the parent and the child, are important in effectively treating a mentally ill parent.

Adult-focused interventions: Profes- sionals working with mentally ill adults need to inquire about their status as parents and their family circumstances, including age and gender of all children, their liv- ing and caregiving arrangements, custody or visitation issues, and children’s mental health and emotional development.

Target areas for interventions include: a) psychoeducation about their mental ill- ness; b) support and education regarding reproductive decision making and perina- tal healthcare; c) coping with custody loss and visitations; d) parenting skills, includ- ing understanding normal child develop- ment and how to stimulate and play with children; and e) a focus on coping with past

Asthma From page 1

functioning of a parent, specifically by affecting their quality of life.

Caregiver quality of life For parents of children with asthma,

caregiver quality of life refers to how the parent is adapting to the child’s illness, how burdensome the caregiver finds management of the child’s illness, and how much the child’s illness affects the caregiver’s emotional functioning and ability to complete daily activities. For instance, a caregiver might find him or herself worrying about the child’s symp- toms throughout the day, might find it hard to sleep at night, or might have to take multiple days off from work to care for the child with asthma.

In turn, parents experiencing a poor quality of life have the potential to mis- manage their child’s asthma. The conse- quences of poor caregiver quality of life might include an increase in the child’s asthma symptoms, hospital visits, or even child emotional distress.

It’s important to recognize that parent quality of life has significant implications for child health outcomes in many pedi- atric chronic illnesses other than asthma. For example, in a recent study assessing maternal depression in pediatric epilepsy, Dr. Mark Ferro and colleagues (2011) found that factors such as poor family functioning, fewer family resources, and greater family demands put a mother at risk for more depressive symptoms.

Healthcare providers, clinicians, and others working with children are in a unique position to increase awareness about the parents’ quality of life and in

this way enhance the overall management of a child’s disease.

Sociocultural environment Quality of life can be influenced by

an individual’s socioeconomic condi- tions and environment, and related daily stresses can affect how the illness is man- aged. For example, parents from urban backgrounds may experience their child’s asthma in the presence of environmen- tal and financial stressors. For caregivers who are already burdened with stresses related to urban living (e.g., keeping their child safe), managing their child’s asthma effectively and navigating the healthcare system appropriately may prove to be challenging. This would be particularly so for families with limited English fluency.

In addition, cultural beliefs about the causes of asthma, the necessity of med- ications, alternative means for treating

Copyright of Brown University Child & Adolescent Behavior Letter is the property of John Wiley & Sons, Inc.

and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright

holder's express written permission. However, users may print, download, or email articles for individual use.