Copmi Children of Parents With a Mental Illness

1. Copmi Children of Parents With a Mental Illness Issues & Challenges Dr Adrian Falkov Consultant Child & Adolescent Psychiatrist adrian.falkov@hunter.health.nsw.gov.au

2. Issues & Challenges • Stigma of mental illness • Multiple, competing perspectives • Parenting is a mental health issue • Mental illness affects all family members • Partnership & collaboration • Children are not little adults • What is Copmi?

3. Crossing BridgesHistory • Canavan and Clark (1923) the mental health of 463 children from dementia praecox stock • Janet (1925) • Preston and Antin (1933) A study of the children of psychotic parents • Huschka (1941) psychopathological disorders in the mother • Buck & Laughton (1959) family patterns of illness: the effect of psychoneurosis in the parent upon illness in the child • Rutter (1966) children of sick parents: an environmental and psychiatric study • Rieder (1973) the offspring of schizophrenic parents: a review • Beardslee et al (1983) children of parents with major affective disorder: a review • Watt, Anthony, Wynne & rolf (1984) children at risk for schizophrenia: A longitudinal perspective • Asarnow (1988) children at risk for schizophrenia: converging lines of evidence • Downey and Coyne (1993)

4. Evidence Framework - Parenting is a Mental Health Issue • Quantitative (epidemiological) • Qualitative (Impacts & influences on children & parents) • Carers, Caring & Loss • Insufficient evidence base for ‘copmi’ specific interventions

5. 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: • Direct effects of abuse & neglect • Absence of sufficient protection against life events & losses • Early traumatic & later susceptibility to MI & poor adjustment • Mechanism for transmission of adversity

6. Early, Lifelong & Generational Influences The links between mental health & parenting thus begin early in life, are evident across the lifespan & are an important determinant of health & social outcomes in succeeding generations

7. Prevalence of ParenthoodEpidemiological Evidence • National Household Survey of Psychiatric Morbidity in GB (Melzer et al ’95) • Prevalence of any neurotic disorder (especially depr, mixed anx-depression & alcoholism) highest among lone parents • MH of Children & Adolescents in GB (Melzer et al ONS survey ’00) • Children with parents who screened positive on the GHQ were 3 X more likely to have a mental disorder than those whose parents had sub-threshold scores • Proportion of children with mental disorders increased steadily with parental GHQ score increases   • National Comorbidity Survey USA (Nicholson et al ’00) • 68% of women with disorders are mothers; 57% of men with disorders are fathers

8. Gender, Class & Mental Health Brown & Harris – working class women with children: • > 4 times as likely as middle class women to become depressed in the presence of an adverse life event • Vulnerability factors included: • Presence of 3 or more children in the home • Absence of a close confiding relationship • loss of mother before 11

9. Separation and Consequences of Loss Complex interplay between mental illness and loss, both physical and emotional. Losses include: • Short term, crisis related separation with hospitalisation & fostering • Permanent changes in family composition and children’s carers as a direct or indirect consequence of mental illness • Suicide

10. Impacts • Children • Age, gender, temperament, IQ, health, ethnicity • Quality of relationships • Life events • Experience & type of parental mental illness • Protective factors and supports • Parents • Individual factors • Parenting • Family of origin experiences • Practitioners • Training, location, support & supervision • Working together

11. What is ‘Copmi? • The experience of mental illness – every family in the land? • An inclusive approach - Adult & child; MH & Social Care; Support and protection; hosp & community • A systemic approach - Family as fundamental unit – targeting relationships • A case for change – service reform • A collaborative approach - Working better together • A preventive approach – harnessing diversity

12. Assessing Need Conceptual Underpinnings • Family Model (Crossing Bridges) • Framework for Assessment of Children In Need (DoH UK) • Continuum of need

13. 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

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

15. The Continuum of Ch-P-Prof Interaction Eligible families can be found across all services. The challenge is matching levels of assessed need with appropriate resources. Mapping children’s contact with services would include: • Well children & those with hidden needs - not known to services • Child carers - resilient but in need of support • Child in need - vulnerable and in need of services • Child protection - vulnerable and in need of services andprotection • Child fatalities - severely maltreated or killed

16. Working TogetherParental Mental Illness & Child Protection Although the majority of mentally ill parents do not abuse their children (and the majority of those who abuse children are not mentally ill), it is important that the needs of all children and parental capacity to meet those needs, including ensuring their safety, are routinely considered

17. PMI & Child Protection • Anecdotes involving all psychiatric diagnoses • Mainly physical abuse &/or neglect • Improved methodological approaches implicating: personality disorder Alcoholism Depression Drug abuse • Co morbidity increasingly relevant – PADD The triad of underlying PD associated with intermittent depression & self harm, complicated by substance abuse in a parent carries a particularly poor prognosis for dependent children

18. Child Fatalities Associated With Parental Psychiatric Disorder • Resnick (’69) • Gibson (’75) • D’Orban (’79) • McGrath (’92) • Wilczynski (‘95, ’97) • Falkov (’96) • Southall et al (’97) • Safety first (5-year report of the national confidential inquiry into suicide & homicide by people with mental illness’01) • NSW Fatal Assaults Report (’02 – MI perpetrators responsible for nearly 20% deaths)

19. Fatal Child Abuse & Parental Psychiatric Disorder ‘ … when retrospective analysis is contextualised it is debatable as to how many deaths of individual children could have been predicted &/or prevented. The importance of the tragedy & ‘lesson learning’ may lie less in the prevention of individual deaths & more on improved support & protection procedures & practices which can impact on the much larger group of children who are abused but not killed. They constitute the ‘at risk’ population from which many fatalities will arise’

20. Prediction & Prevention of Rare Events When death is the outcome measure you either have obvious failure or an inability to measure success without very large numbers

21. Resilience Children Who Adapt Well • Older age at onset of parental illness • More sociable, able to engage adults, easier temperament • Greater cognitive abilities • Discrete episodes of parental illness with good return of skills & abilities between episodes • Alternative support from adults with whom child has positive, trusting relationship • Experience of success outside the home (educational, social, sporting, hobbies)

22. Service InitiativesLiaison Between Child & Adult MH services • FAMILI - Families And Mental Illness Initiative (UK) • Marilyn Murphy, Ulrike Antweiler, Geraldine Xibberas • FaMHLiS - Family Mental Health Liaison Service (UK) • Tom Craig; Nadia Davis; Hillary Williams, Chris hart • Copmi clinic (WS/CHW) • Deborah Finney, Trish Brady, Ros Phillips, B. Stathis

23. Differing Perspectives, Common ChallengesWorking Across Multiple Interfaces • Who is the core ‘client’? Child vs adult rather than child and parent (family) • Blinkered approaches MH vs social care rather than MH and social care • Protecting resources ‘Mine vs yours’ rather than ‘ours’ • Anxiety What is ‘child protection’ and what is ‘mental illness’?

24. Differing Perspectives, Common ChallengesWorking Across Multiple Interfaces • Training & experience Concern about lack of appropriate skills and knowledge or the converse - over-confidence (‘we do it anyway’) • Assessment - of what? Ms/illness prognosis; Parenting; Child (mental) health; Risk (harm to self /other) • Intervention Support vs protection rather than support and protection • Confidentiality (vs absence of good practice) • Under-resourced and overstretched services

25. Policy Context There’s Never Been a Better Time … • NMHP (03-08) • National Workforce Standards • Aicafmha (Principle & Actions for Services & People working with COPMI) • RANZCP Position Statement • RCPsyches - UK (Pts as Parents; Being Seen & Heard) • DoH - UK (Crossing Bridges) • DoH - NSW (IPC; Parenting for MH; School Link; COPMI; CAMHSNET)

26. Patients As Parents The Royal College of Psychiatrists (UK) Council Report (02) www.rcpsych.ac.uk

27. Copmi: A strategy for NSW • Educate & train all MH staff to ensure they have requisite knowledge, attitudes & skills to: • Identify, define & meet needs of Ch & their MIPs • Intervene early, treat effectively & minimise or prevent relapse • Establish care pathways protocols • Set minimum standards • Evaluate & monitor clinical standards & outcomes • Develop models of best practice • Involve consumers in process of service reform

28. Meeting NeedParenting is a MH Issue • Know which pts are parents (MHOAT) • Ask about & talk to children • Read ‘Pts as Parents’ -roles & responsibilities for all psychiatrists www.rcpsych.ac.uk • Visit COPMI website www.aicafmha.net.au • Attend Crossing Bridges training • Talk to & make links with colleagues in other services

29. Crossing BridgesPrevention Strategies • Reduce child exposure to parental symptoms • Assertively treat parental illness • Promote positive parenting • Reduce exposure to parental discord • Educate parents about mental illness • Educate children about MI & ways of coping • Promote open discussion about MI in families • Facilitate support outside the home • Promote opportunities for relationships & achievements within school • Address socio-economic factors

30. Working Together Assessment Important factors related to mental illness include: • Prognosis of mental illness (chronic but moderately severe symptoms vs. Florid remitting and relapsing with good inter-episodic functioning) • Co-morbidity and diagnostic uncertainty • Treatment resistance and failed treatment • Compliance • Treating symptoms in isolation is insufficient • Adequate support for children whilst parents are receiving treatment

31. Exchange of Information and Confidentiality • Communication should occur as early as possible following referral • Confidentiality not a cover for the absence of good practice, or a platform for overzealous advocacy on behalf of a client/patient • If difficulties arise, clarity should be sought about whose interest is or is not being served by sharing information as well as the potential consequences about sharing and not sharing information

32. Impacts on ChildrenStatistical Risk Liabilities • Aggregated data indicate that these children have a 70% chance of developing at least minor adjustment problems by adolescence • With 2 MIPs there is at least a 30 – 50% chance of becoming seriously mentally ill (Rubovits) • Regarding specificity, a child with an affectively ill parent has a 40% chance of developing affective disorder by age 20, compared to 20-25% risk in the general population (Beardsley)

33. Multiple Influences & Individual Differences in Adjustment • As the statistical risk liabilities show, not all children whose parents are MI will inevitably experience difficulties • It is the combination of bio-genetic inheritance and psychosocial adversities associated with MI adults which increases the likelihood that children will experience difficulties • Factors within the child such as age, gender, temperament, IQ and genetic liability interact with & are influenced by the specificity, severity, chronicity, pattern and co-morbidity of a parents illness together with family and socio-demographic factors