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The extent to which parental mental illness effects the standard of parenting and children's safety or welfare hinges on a number of factors. A small number of children die or are seriously harmed by a mentally ill parent. Many more children suffer less dramatic effects as their own development or mental health becomes compromised. There is a 'hidden problem' around children who care for a mentally ill parent ('young carers') who may miss out on many opportunities. The 'scale of the problem' is not known but it has been estimated that psychiatric morbidity amongst parents is about 16%. There are many barriers - legal, structural, professional, financial - to the creation of services which tackle both parental mental illness and children's welfare but some interesting initiatives have been set up.
Parental mental illness takes many different forms. Its impact upon children varies according to a host of factors. One is the severity and duration of the illness. For instance, a temporary and minor illness handled by primary care services is likely to be much less disruptive to family life than a severe and chronic psychotic illness requiring lengthy hospitalisation. Other variables include the child's age and resilience, the presence or absence of a 'wel l' parent/ carer and the extent to which the illness pervades all aspects of family life (Rutter, 1989). It is tempting, but inadvisable, to give undue weight to the psychiatric diagnosis. As Reder et al (1993) point out, the telling factor is not the diagnosis as such but the parental behaviour.
So, how does parental mental illness affect children? The research can be distilled into three sub-headings the impact upon parenting, direct effects on children and children who care for a mentally ill parent.
There is a body of literature and research (Murray, 1996; Ethier et al, 1995; Dore, 1993; Sheppard, 1993) which points to those suffering mental illness having impaired social performance and disproportionately conflictual relationships. Parenting may be adversely affected. Ethier et al (1995), for instance, found that clinically depressed mothers were more likely to speak less often to children, enforce obedience unilaterally and react in more hostile and irritable fashion. Murray (1996) produced similar findings of social disadvantage, relationship problems with children and the latter having increased levels of behaviour difficulties.
A small study of parents who use mental health services (Hugman and Phillips, 1993) showed that all thought their relationships with their children had suffered at some point. It is generally held that parental mental illness is a risk factor in respect of child abuse (Sheppard 1993). Forthcoming research into serious injuries sustained by children under 24 months suggests many parents had poor mental health (Dale, Green and Fellows, forthcoming) though a formal diagnosis of mental illness was relatively rare. Research (cited in Dore, 1993) which has inquired into causal relationships between parental mental illness and abuse has produced mixed findings.
There is a second body of literature/ research which has covered much of the same territory but from the perspective of child welfare. A pioneering paper by Kempe et al (1962) posited that psychiatric factors were probably 'of prime importance ' (Kempe et al, 1962, p.17) in the aetiology of child abuse. Subsequent research has suggested that the causes of child abuse are generally more complex and multi-factorial. Nonetheless, Bell et al (1995) found parental mental illness recorded as a factor in 13% of cases referred for child protection concerns. A number of children suffer permanent injury or die at the hands of mentally ill parents (Falkov, 1995), typically during an acute phase of an illness. Also a small number are seriously harmed or die as a consequence of a carer, generally the mother, suffering from Munchausen's Syndrome by Proxy (see e.g. Bools et al, 1994).
Nonetheless, the greatest risk to the majority of children is not one of life and limb. It is rather the threat to their own attachments, development and mental health (Rutter, 1989). Rutter and Quinton (1984) concluded that one-third of the children of new psychiatric cases exhibited a persistent disorder, this being twice the rate found in the control group. A recent study (Singer et al, 2000) found high rates of psychiatric disturbance within a small sample of children of psychiatric in-patients, many of these children being unknown to services. Reid and Morrison (1983) suggested that young children are particularly vulnerable, as are the children of psychotic parents. The issue of whether psychosis poses more risk than, say, depression is a typically complex one within this field and, as with many issues, best treated with caution. For instance, Cassell and Coleman (1995) posit that children are at increased risk if incorporated into parental psychotic ideation; conversely, other research (see Dore, 1993) showed no differences in outcomes between children of psychotic and depressed parents.
Finally, there is a third germane body of literature/research which focuses on children who care for a mentally ill parent. These are commonly referred to as young carers though this is mostly employed as a generic term encompassing children who care for parents for a number of different reasons, including parental physical disability or physical illness. Estimates of the numbers of young carers nationwide vary between 10,000 and 40,000, of which about one-third care for a mentally ill parent (Dearden and Becker, 1995). Care is more likely to be provided by girls than boys and may well have a physical and emotional component. It is also likely to be provided to younger siblings as well as ill parents. A number of personal accounts (Marlowe, 1996) and reports (SSI, 1996) point to the difficulties experienced by a proportion of young carers. The problem is not the caring per se - indeed, many young carers report a wish to undertake this role. It is the missing out on educational, social and leisure activities that is sometimes concomitant with this role. Young Carers are something of a 'hidden problem', being either unknown to services or being left to cope.
Our own study (NSPCC, 1997) contained some poignant accounts of children acting as carers and of the costs thus incurred. It also showed that many of these children had significant experiences of loss, self-blame and stigma.
Accurate data as to the percentage of mentally ill parents who have dependent children is not systematically recorded (Falkov, 1997). Indeed, at the point of first contact with mental health professionals many recipients of mental health services are not identified as parents (Blanch et al, 1994). Thus, information as to the scale of the problem is largely based on estimates. Within this context, Gopfert estimates that one half of all mentally ill adults are parents living with dependent children (Gopfert et al, 1996). Meltzer et al (1995) estimate the psychiatric morbidity among parents nationally to be 16%.
There are a number of studies which examine the prevalence of mental illness amongst adults (not necessarily parents) which suggest that prevalence is governed to some extent by gender, ethnicity and class. It is known, for example, that twice as many women as men suffer from depression (Sheppard, 1993) and that depression is a particularly common disorder amongst women of child-bearing age (Downey and Coyne, 1990). A seminal work established that working class women were four times more likely to suffer from a psychiatric disorder than their middle class counterparts (Brown and Harris, 1978). There are differential rates of prevalence within different cultures. This may reflect a link between social stress (racism, unemployment, poverty etc) and mental illness (see e.g. Littlewood and Lipsege, 1989). However, the picture is complex as there is not a clear one-to-one relationship between social disadvantage and mental illness. One difficulty is that the term 'mental illness' is itself culturally-bound; mental health may manifest itself differently in different cultures. Community based studies suggest that prevalence rates are about 1% for schizophrenia, 5% for depression, 10% for personality disorders and 10-30% for anxiety disorders (quoted in Cleaver et al, 1999).
Research into the field of mental illness is mired in definitional/ methodological difficulties. For instance, a number of studies might all examine 'mental illness' but be looking at very different phenomena. Some studies are drawn from samples of psychiatric in-patients whilst others are drawn from the community at large, depending mostly on respondents' self-report. It does not necessarily follow that the findings drawn from a psychiatric sample examining psychosis can be compared or integrated with those examining those suffering depression in the community. Equally, some studies include alcohol and substance abuse whilst others exclude these.
There is a significant body of recent literature/ research examining the ways professionals and agencies tackle parental mental illness and child welfare (Gopfert et al, 1996; Weir and Douglas, 1999; DH, 1998; NSPCC, 1997). Essentially all argue that the key to good service provision is the integration of services and a 'holistic' approach - one in which the needs of all family members can be considered.
Recent cross-national comparative research (Hetherington et al, 2001) suggests that some problems i.e. keeping a clear focus on the child and co-ordinating services are not exclusive to this country. However, England does seem to have specific problems 'derived from the system' such as risk avoidance, professional pessimism and a shortage of resources. The literature as a whole points to there being many barriers to integrated and effective service provision within the UK, viz:
Notwithstanding the many barriers that exist, there are a number of recent changes in practice or initiatives have sought to tackle parental mental illness and children's welfare in an integrated manner. Some are specific to parental mental illness, others tackle this as part of a broader remit. Examples include:
Blanch, A. K., Nicholson, J. & Purcell, J. (1994) Parents with severe mental illness and their children: the need for human services integration. Journal of Mental Health Administration, 21(4): 388-396.
Bools, C. N. , Neale, B. and Meadow, R. (1994) Munchausen Syndrome by Proxy: a study of psychopathology. Child Abuse and Neglect, 18(9): 773-788.
Brown, G. W. & Harris, T. (1978) Social origins of depression. London: Tavistock.
Cassell, D. and Coleman, R. (1995) Parents with psychiatric problems. In: P. Reder and C. Lucey (eds) Assessment of parenting: psychiatric and psychological contributions. London: Routledge.
Cleaver, H., Unell, I. and Aldgate, J. (1999) Children's needs - parenting capacity: the impact of parental mental illness, problem alcohol and drug use, and domestic violence on children's development. London: The Stationery Office.
Cohler, B. J., Stott, F. M. and Musick, J. S. (1996) Distressed parents and their young children: interventions for families at risk. In: M. G pfert, J. Webster and M. V. Seeman (eds) Parental psychiatric disorder: distressed parents and their families. Cambridge: Cambridge University Press.
Dale, P., Green, R. and Fellows, R. (2002) What really happened? child protection case management of infants with serious injuries and discrepant parental explanations. London: NSPCC.
Dearden, C. and Becker, S. (1995) Young carers: the facts. Loughborough: Young Carers Research Group.
Department of Health (1995) Child protection: messages from research. London: HMSO.
Dore, M. M. (1993) Family preservation and poor families: when 'home-building' is not enough. Families in Society, 74(9): 545-556.
Downey, G. and Coyne, J. (1990) Children of depressed parents: an integrative review. Psychological Bulletin, 108(1): 50-76.
Ethier, L. S., Lacharite, C. and Couture, G. (1995) Childhood adversity, parental stress and depression of negligent mothers. Child Abuse and Neglect, 19(5): 619-632.
Falkov, A. (1995) Study of Working Together 'Part 8' Reports. London: Department of Health.
Falkov, A. (1997) Parental psychiatric disorder and child maltreatment: part 1: context and historical overview. Highlight [NCB], 148.
Fiedler, B. (1996) Young carers: making a start: report of the SSI fieldwork project on families with disability or illness October 1995 - January 1996. Wetherby: Social Services Inspectorate.
Gibbons, J., Conroy, S. and Bell, C. (1995) Operating the child protection system: a study of child protection practices in English local authorities. London: HMSO.
G pfert , M., Webster, J. and Seeman M.V. (1996) Parental psychiatric disorder: distressed parents and their families. Cambridge: Cambridge University Press.
Green, R. et al (1997) Long term problems ??short term solutions: parents in contact with mental health services: a report for the Department of Health and the Brent Area Child Protection Committee. London: NSPCC.
Hall, A. (1996) Parental psychiatric disorder and the developing child. In: M. G pfert, J. Webster and M. V. Seeman (eds) Parental psychiatric disorder: distressed parents and their families. Cambridge: Cambridge University Press. p.17-41.
Hetherington, R. et al (2001) The welfare of children with mentally ill parents: learning from inter-country comparisons. Chichester: Wiley.
Hugman, R. and Phillips, N. (1993) 'Like bees round the honeypot': social work responses to parents with mental health needs. Practice, 6(3): 193-205.
Kempe, C. H. et al (1962) The battered child syndrome. Journal of the American Medical Association, 181: 17-24.
Littlewood. R., and Lipsedge, M. (1989) Aliens and alienists: ethnic minorities and psychiatry. 2nd ed. London: Routledge.
Maitra, B. and Jolley, A. (2000) Liaison between child and adult psychiatric services. In: P. Reder, M. McClure, and A. Jolley (eds) Family matters: interfaces between child and adult mental health. London: Routledge.
Marlowe, J. (1996) Helpers, helplessness and self-help: 'shaping the silence': a personal account. In: M. G pfert, J. Webster and M. V. Seeman (eds) Parental psychiatric disorder: distressed parents and their families. Cambridge: Cambridge University Press. p.99-106.
Mayes, K., Diggins, M. and Falkov, A. (1998) Crossing bridges: training resources for working with mentally ill parents and their children. London: Department of Health.
Meltzer, H. et al (1995) The prevalence of psychiatric morbidity among adults living in private households. London: HMSO.
Murray, L. (1996) Personal and social influences on parenting and adult adjustment. In: S. Kraemer and J. Roberts (eds) The politics of attachment: towards a secure society. London: Free Association Books. p.43-61.
Reder, P., Duncan, S., and Gray, M. (1993) Beyond blame: child abuse tragedies revisited. London: Routledge.
Reid, W. H. and Morrison, H. L. (1983). Risk factors in children of depressed parents. In: H. L. Morrisson (ed) Children of depressed parents: risk, identification and intervention. New York: Grune and Stratton.
Rutter, M. and Quinton, D. (1984) Parental psychiatric disorder: effects on children. Psychological Medicine, 14: 853-880.
Rutter, M.(1989) Psychiatric disorder in parents as a risk factor for children. In: D. Schaffer (ed) Prevention of mental disorder, alcohol and other drug use in children and adolescents. Rockville, MD: Office for Substance Abuse, USDHHS.
Schuff, G. H. and Asen, K. E.(1996) The disturbed parent and the disturbed family. In: M. G pfert, J. Webster and M. V. Seeman (eds) Parental psychiatric disorder: distressed parents and their families. Cambridge: Cambridge University Press. p.135-151.
Sheppard, M. (1993) Maternal depression and child care: the significance for social work and social work research. Adoption and Fostering, 17(2): 10-15.
Singer, J., Tang, S. and Berelowitz, M. (2000) Needs assessment in the children of parents with major psychiatric illness. In: P. Reder, M. McClure and A. Jolley (eds) Family matters: interfaces between child and adult mental health. London: Routledge.
Stanley, N. and Penhale, B. (1999) The mental health problems of mothers experiencing the child protection system: identifying the needs and appropriate responses. Child Abuse Review, 8(1): 34-45.
Weir, A. and Douglas, A. (1999) Child protection and adult mental health: conflict of interest? Oxford: Butterworths.
White, S. (1996) Regulating mental health and motherhood in contemporary welfare services: anxious attachment or attachment anxiety? Critical Social Policy, 16(1): 67-94.
Gopfert, M., Webster, J. and Seeman, M. V. (eds) (1996) Parental psychiatric disorder: distressed parents and their families. Cambridge: Cambridge University Press.
Mayes, K., Diggins, M. and Falkov, A. (1998) Crossing bridges: training resources for working with mentally ill parents and their children. London: Department of Health.
This research briefing is based on a review of research and literature. It reports the findings and views of a range of authors. These views are not necessarily the views of the NSPCC.
Although the websites listed here are checked regularly, the constantly changing nature of the internet means that some sites may alter after we have viewed them. The NSPCC is not responsible for, nor does it necessarily endorse, the content of these external websites.
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