Think Child, Think Parent, Think Family

1. 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 adrianfalkov@optusnet.com.au

2. We Know… • 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

3. … • Major public health opportunity - implics for better identification, intervention & prevention • Improving life chances & lived experiences for parents & children • Family as NB target & mechanism for change • 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

4. … • 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

5. Also… • 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

6. 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

7. The Family GenesRecurrent, early onset Major Depression • 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

8. Gene environment interplay • 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

9. So… What should it look like? • Adults • briefer, less frequent illness episodes • Reduced hosp, relapse • Improved cap to meet children’s neds • Harmonious relationships, social connections • Productive roles, educ & employment • Children • 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 • Cohesion, harmony happiness as a result of accessible flexible equitable safe responsive services

10. Comprehensive service? • Diagnostic • Severity • Population-based • All family members • Individuals v relationships • MH Promotion, prevention

11. A Vision For Change? • Multiple, competing perspectives • 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 • 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

12. But… Challenges and Dilemmas • 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

13. Invisible ChildrenAMH 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’

14. Children’s UnderstandingTom, 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…’

15. 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?

16. 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

17. 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 • 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

18. Dual diagnosis? • 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

19. Ingredients of Complexity • 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

20. ‘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: • 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’

21. Resources – caught between service & science imperatives • 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

22. 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

23. 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

24. Competing needs • Interplay between multiple psychosocial vulnerabilities & socioeconomic disadvantage over the lifespan and across generations • Dual diagnosis is the norm for State-funded, public sector services

25. Strategies, tactics and approaches • 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

26. SCIE Guidelines Comprehensive approaches • 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)

27. Conceptual Models • Continuum of need • Family Model – Crossing Bridges • Family Focussed Assessment

28. Crossing BridgesKey Principles 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

29. Crossing BridgesThe Family Model 4 Stressors & vulnerabilities 1 Adult mental health 2 Child dev & mental health 3 Parental & fam relationships 4 Strengths, resilience & resources

30. IdentificationEvery Family in the Land? • 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

31. Assessment – Key Areas • Who to assess • The child • The ill parent • Partners & other key people in the child’s life • What to assess – key domains • 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 • Talking with children whose parents are MI or abusing substances • Talking with parents / carers who are / may be MI

32. FaMHliSTalking 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?’

33. Family intervention • Early (age – eg children) • Quickly (stage – of illness) • Identify, assess, intervene, review • Family as key target for early intervention • +ve impact on children reduces burden for parents • +ve impact on parents promotes children's wellbeing and safety

34. 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’

35. Parenting is a Mental Health Issue • 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: • 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

36. Working Better Togetherprofessional 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

37. Working better together • 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

38. Working better together • 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

39. Evaluation • Of what? • 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

40. 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.’

41. Children’s understanding of parental psychiatric disorder Improving outcomes for families How can children understand what parents can’t explain?

42. 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.

43. 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.’

44. Crossing Bridges Prevention • 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

45. Conclusions • 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

46. Conclusions Improve identification, assessment and intervention: • 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)

47. Conclusions • 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?

48. Conclusions • Use Media opportunities • Promote positive mental health & tackle stigma • Use evidence on prevalence of parenthood & impact on children to • 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