Effects on children growing up with mentally ill parent(s)

The needs, however, of children with parents who have a serious mental illness (e.g., psychosis) have for a long time been underrecognized. Mordach and Hall (2002) considered that current research has failed to focus on issues from the child's perspective.

Understanding the child's perspective is important, given that research has shown that, often, such children manage to hide their feelings and have misconceptions about their parent's illness (Marsh ; Dickens, 1997).These children have been shown to have worries specific to their family situation—concerns such as whether they, too, will develop the same illness as their parent, whether their parent will need to be in hospital permanently, and whether they are the cause of their parent's mental health problems (Gerace, Camilleri, & Ayres, 1993; Marsh, Appleby, Dickens, Owens, & Young, 1993). Despite such specific concerns, there is evidence that the psychological needs of children of mentally ill adults are often not met. Caton, Cournos, Felix, and Wyatt (1998) found that only half of their sample of 39 offspring (aged between 13 and 48) of psychiatrically ill parents had ever spoken with a health professional about their parent's illness, whereas Ostman and Hansson (2002) found that just over half of the well spouses in their sample considered that their child needed further professional support related to the other parent's mental illness.

The issue of support for these children is therefore paramount. As with many ongoing stressors, individuals are reluctant to disclose their family situation to others for fear of the attached stigma. This results in a sense of isolation for the child, and the burden of responsibility for dealing with the day-to-day difficulties of having a mentally ill parent can often rest solely with the child or his or her siblings. The argument for supportive services to help these children, and their families, has understandably therefore been raised. Byrne et al. (2001), in a Canadian study of families with a parent with an affective disorder, found that many of the participants wanted their whole family involved in the treatment, not just the adult with the illness.

In a review of services and studies provided for this population, the Australian Infant, Child, Adolescent and Family Mental Health Association (2001; AICAFMHA) summarized the recommendations of previous reports. These recommendations include providing the child with education regarding mental illness and helping children develop resilience and coping skills. Similar practice guidelines are given by the Royal College of Psychiatrists (2002). Luntz (1995); Cowling (1999); Hinden, Biebel, Nicholson, Henry, and Stier (2002); and the British Columbia Schizophrenia Society (2003; BCSS) have reviewed programs that include such aims for children of mentally ill parents.These programs aim to provide support to the child, act as his or her advocate, increase the child's knowledge of the parent's mental illness, and improve the parent-child relationship.

Some programs have specific components for separate members of the family, whereas others are focused just on the children. Hinden et al. described five programs in the United States, such as the Invisible Children's Program in Orange County, New York, whereas Cowling (1999) described several Australian programs, such as the Children and Mentally Ill Parents Project (CHAMPS) camp (Cuff ; Pietsch, 1997). BCSS (2003) briefly described over 20 programs in Canada, the United States, and Australia. Various positive outcomes have been reported for such programs, including reduced hospitalization of parents, reduced denial of family problems by the children, an increased capacity for the child to share his or her concerns with the group, an increase in the child's knowledge about mental illness, and improved social skills.The outcome details of most programs, however, are only reported in in-house documents rather than in peer-reviewed journals, which can therefore make it difficult for clinicians to access the information.

Hinden et al. also discussed the lack of an empirically supported evidence base for many of these services—thus, although most programs may report beneficial outcomes, few have empirical evidence to support their claims. We hope that the information reported in this article, therefore, will supplement that from others and provide empirical evidence that clinicians and the community can use when deciding what is current good practice in helping children with a parent with a mental illness.MethodParticipants A total of 25 children between the ages of 5 and 15 (M = 10.8, SD = 2.

0), from 18 families, participated in three separate programs conducted in Australia (two programs; n = 19) and Canada (one program; n = 6). Two thirds of the children were girls, and 11 came from English-speaking backgrounds, with the remainder having a variety of cultural backgrounds (e.g., Vietnamese, Cambodian, Greek, Sri Lankan). All the children had sufficient command of English to participate in the program, although some required assistance with completing the evaluation measures.The diagnoses given to the parents by the referring health workers included affective disorders (n = 17; a mixture of major depression with or without anxiety disorders or bipolar disorder) and schizophrenia (n = 8).

For 17 of these parents, the diagnosed disorder had been present for more than 5 years. In addition, 4 children had a sibling with a diagnosed disorder; these were autism (n = 1), obsessive-compulsive disorder (n = 1), eating disorder (n = 1), and one not specified. All these sibling disorders were reported to be for less than 5 years. Fifteen of the children were living with both their parents, 7 lived with just the parent with the mental illness, 2 lived with their nonmentally ill parent, and 1 lived with relatives.ResultsOf the 25 children, 17 attended all 3 days of the program, with the remainder attending 2 days.

Reasons for missing a day included illness, previous commitments, and parental illness that required the child to help run the family business or look after the parent. Related t tests were used to assess any changes from preratings to postratings on the knowledge and life skills measures, and the results from these are shown in Table 1. On eight of the nine self-report questions concerning the child's knowledge of mental illness there was a significant improvement by the end of the 3-day program.On all of the questions regarding life skills there was also significant improvement in children's self-ratings. The point-biserial correlation coefficient (rpb ) values indicate that these changes were not only statistically significant but also clinically significant (Matthey, 1998).

Inspection of Table 1 also shows that for some questions there were considerable missing data. This was primarily due to the children not attending either Day 1 or Day 3 and occasionally due to a participant failing to answer that question.The children's feedback form indicated that all the participants felt the program was helpful. Some of the comments written by the children in response to the question about what they liked most or what were the things they had learnt were as follows: “I know a lot more because Erica [the facilitator] has explained lots of things I was worried about”; “It was really fun and everyone was envolved [sic]”; “I am not the only one who has a family member who is sick. It's not Dad's fault”;“It was fun doing the card and droring [sic]”; “I liked the games and meeting new people”; “I learnt that mental illness can't be caught like a cold. And people with schizophreniah [sic] can hear things and see things that aren't real and they have dollosion [sic] and hollusionations [sic]”; “I learnt that friends are very important to us and some people with mental illness can lose or get weight”; “I have told other children who don't know what they are talking about what depression really means”; “I learned a lot of problem solving at home”; “I learnt that it's [mental illness] not our fault”; “It was good cause now I can express my fellings [sic] more—thanks!”; “I learnt that illegal drugs don't help”; and “I learnt that you can call Kidshelp Phone instead of talking to your parents, if your [sic] shy.

”The majority of children indicated that there wasn't anything they didn't like about the program. There was the occasional comment about not liking the food, singing, writing, meditating, or the hot weather (at the Australian site). The few additional comments about things children disliked were as follows: “Rest time in the afternoon and having to leave”; “Filling in sheets”; “The fact that I'm the eldest”; “Embarrassed when I first arrived, cas [sic] there weren't any little people” (from the 5 year old); “Sitting to [sic] long”; and “When we have to listen to people talk about their mother.”The majority of children indicated that either there wasn't anything else that would have helped them or they didn't know. Some of them indicated that they would have liked a 4-day or even longer program.

The additional comments about further things that would help were “How to deal with dethe [sic: death]” and “To get more attached to my dad.” Only 7 of the 18 families returned their feedback forms (10 forms returned—three couples completed a form each).All of these felt the program had been helpful for their child. Their comments about benefits, learning, and changes included the following: “The program gave the children a real insight into the hows and whys of depression at a level they could understand”; “[My son] has adopted a caring attitude that notices when I am feeling worse. He knows when to advise me what to do sometimes”; “The program was excellent and met [my son] where his understanding was”; “[My son] has a less frustrated attitude at what I can't do”; “The student, through this education program, is able to become more tolerant and open-minded and less judgemental.Through guidelines learnt, [my daughter] has the ability to listen, observe and recognise symptoms associated with mental illness.

By recognising symptoms she has helped others”; “The program has also given to this family, a sense of belonging without pre-judgement”; “This is the first time we've been able to discuss mental illness as a family”; “[My daughter learnt] how to deal with her emotions/feelings more effectively”; “Great benefits. He is aware now of what mental illness is, what side effects the medications have and knowing that mental illness is like any other illness and not terminal—I think he feels quite relieved”; “We started understanding each other in many different ways”; “More understanding of her sister's difficulties and how normal it is to become frustrated at her and our life”; “[My daughter] seems to be calmer”; and “He also understood that he should express his feelings and thoughts more openly.”Additional comments from the parents included “Would like to share the experience with other children in the family”; “Both parents and children should participate. Really should not be optional for parents. Would be good to have lunch with the children and more for the parents in the afternoon” (Canadian program); and “We missed a day of the program because we didn't know about it.

This would have been good for them to attend.” This study has several limitations that need to be recognized in an interpretation of the data. The knowledge and life skills measures were constructed for this program, and the psychometric properties of the instruments are not known. However, the positive comments by the children correspond to the improvement in their ratings and indicate that the measures have, therefore, a reasonable degree of validity.

Another limitation is the lack of a control group—thus, the changes observed could be due to factors other than the participation in the program or could be due to nonspecific factors inherent in attending any program or service. There is also the consideration of demand characteristics intrinsic to any evaluation of a service provision—the children may have felt the need to report improvement on the items at the end of 3 days, regardless of how they actually felt. If such a demand characteristic is operating, it is obviously made easier because the participants are allowed to see their ratings to each question from the start of the program.However, as stated, without knowing the reliabilities of the instruments and given the shortness of the pre-post interval (3 days), we considered it better to adopt this procedure than presume blind ratings.

We accept, however, that this methodology is open to debate. As with all programs, there are also issues to do with the representativeness of the sample—the children who attended the groups may be different from those who do not wish to attend such programs or who have families who do not want them to attend.Thus, we cannot say whether the SMILES program is suitable for all children with a parent with a mental illness. Also, the low response rate to the parent's feedback form means caution should be applied to these findings. We have no way of knowing whether those who did not respond felt as positively about the program as those who did respond.