IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

J.13

MISCELLANEOUS

CHILDREN OF PARENTS WITH
MENTAL ILLNESS(COPMI)
Christina Schwenck, Hanna Christiansen & Michal Goetz

Christina Schwenck
Professor of special needs
educational and clinical childand adolescent psychology,
Justus-Liebig-University
Giessen, Germany
Conflict of interest: PI of the
project COMPARE emotion,funded by the German Federal
Ministry of Education andResearch

Hanna Christiansen
Professor of clinical childand adolescent psychology,
Department of Psychology,
Philipps University, Marburg,
Germany
Two Chatting Women
with Two Children (Zwei
schwatzende Frauen
mit zwei Kindern) Käthe
Kollwitz (1930). Käthe
Kollwitz Museum Köln

Conflict of interest: PI of the
project COMPARE emotion,funded by the German Federal
Ministry of Education andResearch; co-PI of the researchgroup “The Village” fundedby the Ludwig-BoltzmannGesellschaft, Austria

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the editors or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the editors or IACAPAP endorse their content
or recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2020. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Schwenck C, Christiansen H, Goetz M. Children of parents with mental illness (COPMI). In Rey JM, Martin
A (eds), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2020.

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IACAPAP Textbook of Child and Adolescent Mental HealthChildren of parents with mental illness (COPMI) face multiple psychological,
biological and social stressors that increase their personal risk for thedevelopment of mental disorders. Accordingly, lifetime prevalence ofmental disorders in COPMI is significantly elevated. Furthermore, these children
are at risk of general and specific developmental disadvantages. Despite the fact that
COPMI can be described as the future generation of people with mental illness,
research and intervention on the topic has been neglected for a long time. Still,
health systems in many countries do not allow for preventive measures needed for
COPMI and their families. Moreover, data exist mostly for high-income countries,
whereas we have almost no information about the situation of COPMI in low- andmiddle-income countries, where the majority of children live.

Michal Goetz
Assistant professor of
psychiatry, Department of Child
Psychiatry, Charles University,
Second Faculty of Medicine,Motol University Hospital
Conflict of interest: Worksupported by the Ministry of
Health of the Czech Republic,
grant 17-32478A

The consistency theory (Grawe, 2007) assumes four basic needs that humanbeings aspire to satisfy and protect from harm: attachment, orientation and control,
pleasure, and self-enhancement. When we imagine a child of a mother who suffersfrom depression or a father affected by schizophrenia, it becomes clear that thesebasic needs are commonly not met. A wide variety of difficulties are associated witha mental disorder among parents, for example, the mental disorder might preventthese parents from responding consistently, reliably, and warm-heartedly to theirchild’s needs. They might behave and react in an unpredictable way and it might
be difficult for them to spend quality time and contribute to their children’s selfesteem. In many families, the mental disorder of a parent is not discussed openly or
explained in a way that children can understand, often with the aim of protecting
them or because of insecurities about how to best explain the disorder. However,this can lead to misattributions in the child, leaving them with feelings of guilt
and the assumption that they might be responsible for their parent’s suffering.
At the same time, parents might experience feelings of guilt and low self-esteem
about their role as a parent. Due to loyalty, children may try to compensate by
performing tasks that parents are no longer able to do, like cleaning the house or
caring for younger siblings. They might avoid inviting friends home or talking toother adults about their difficult situation. Caregivers with a mental disorder may
be reluctant to seek help because of stigma or fear over losing custody.
It is clear that both children and parents face difficult situations that
contribute to psychosocial distress and compound the biological mechanisms of thedevelopment of mental disorders. In this chapter we discuss the epidemiology, risk
and protective factors for the transgenerational transmission of mental disorders,and strategies of prevention and intervention in relation to these children.

EPIDEMIOLOGY
Parents with Mental Illness Who Have Children
Globally, there are no reliable data on the number of mentally ill adults
with children, or of children living with at least one parent suffering from a mental
illness. Most of the few studies come from high income countries. For example,
a representative study from Australia found an overall lifetime prevalence of selfreported mental disorders in parents of 37 %. In single-parent households the rate
was significantly higher (50 %) (Johnson, 2018). The prevalence of all disorders
was significantly higher in these children than among those whose primary
caregiver reported no diagnosis, and highest among those whose primary caregiver

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IACAPAP Textbook of Child and Adolescent Mental Health

Table J.13.1 Prevalence of mental disorders among adults who are parents,
according to study
Study(Country)
Johnson et al, 2018
(Australia)
Stambaugh et al, 2017
(US)
Maybery et al, 2009
(Australia)
Luciano et al, 2014
(US)
Royal College of
Psychiatrists, 2015

Representative
Clinical samples:
samples:
Adult patients who
Mental disorders
are parentsin parents
•

37 %

•

18 %

•

50 % in single-parent
households•

Overall, 8 % parents
reported psychologicaldistress
4 % suffered severe
impairment••

20 %-28 %•7 % mothers•

38 % women•

3 % fathers•

23 % men•

68 % women•

57 % men(UK)

Comments•

Severe mental illness

had more severe and comorbid disorders. Recent data from the US indicate that
18 % of parents suffered from a mental illness and 4 % showed severe impairment(Stambaugh et al, 2017). Another representative study found that 38 % of mothers
had a serious mental illness, compared with 23 % of fathers (Luciano et al, 2014).
Finally, a representative study from the UK found that 68 % of women and 57 %of men with mental illness had children (Royal College of Psychiatrists).

Mental Disorders in COPMI

Taken together, thesedata indicate that one to
two thirds of adult patientswith mental disorders
have children, and thatabout one fifth of children
underage live with at least
one caregiver with a mental
disorder (see Table J.13.1)

Several studies report a significantly increased prevalence of mental illness
in COPMI, who are about 2.5 times more likely to develop a mental disorder thanchildren of parents without a mental illness.

MECHANISMS OF TRANSGENERATIONAL
TRANSMISSIONCOPMI are exposed to several biological, psychological and social factorsthat increase the risk of developing a mental disorder. Four different pathways oftransmission can be hypothesized (Santvoort et al, 2015):
1. Multifinality: A specific mental illness in the parent (for example
schizophrenia) increases the risk of multiple mental disorders in theoffspring (for example, for schizophrenia, depression, anxiety disorders
etc.)

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Figure J.13.1

A developmental model of transgenerational transmission of psychopathology (adapted from Hosman et al, 2014)

IACAPAP Textbook of Child and Adolescent Mental Health

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2. Concordance: A mental illness in the parent mainly increases the risk for thesame disorder in the offspring (e.g., children of parents with agoraphobia
are mostly likely to develop an anxiety disorder)
3. Equifinality: Different mental illnesses in parents increase the risk
for similar problems in the offspring (e.g., children of parents withschizophrenia, bipolar disorder, or unipolar depression are more likely todevelop unipolar depression)
4. Specificity: when the child’s problems are specifically related to the parent’s
diagnosis (anxiety disorders in parents increase the risk for anxiety
disorders in the child).
The extent to which the different pathways apply differs between disorders
in parents and children. For severe mental illness, the risk ratio for the same
disorder present in the child as in the parent was found to be higher (3.59; 95 %CI:2.57-5.02) than for a different disorder (RR=1.92; 95 % CI: 1.48-2.49) (Rasicet al, 2014).
Figure J.13.1 presents a model of the transgenerational transmission ofmental disorder adapted from Hosman et al (2014).

Mood Disorders
Unipolar depression and bipolar disorder in parents were found to be
associated with an increased risk for several mental disorders in their children(multifinality). A 30-year longitudinal US study of children of parents with adepressive disorder found a twofold increased risk for a mood or anxiety disorder anda threefold elevated risk for the development of a depressive disorder (Weissman etal, 2016). Onset before puberty, recurrence, poor general outcome, and mortality
were increased in these children. Other studies report similar findings (e.g., Potter
et al, 2012; Goodman et al, 2011).
Children of parents with bipolar disorder have been reported to be 2.7
times more likely to develop any type of psychopathology—such as schizophrenia,
substance use disorder, attention deficit/hyperactivity disorder (ADHD), andanxiety disorders – and four times more likely to develop an affective disorder(Lapalme el al, 1997; Leijdesdorff et al, 2017).

Schizophrenia
Psychoses in parents also seem to be associated with a variety ofpsychopathology in the offspring. A review found that 15 % to 40 % of thechildren developed psychotic disorders themselves (Hameed & Lewis, 2016).
Rates of other mental disorders such as ADHD, anxiety, bipolar, major depression,
conduct/oppositional defiant disorder, and autism spectrum disorders were also
elevated (Leijdesdorff et al, 2017; Reupert et al, 2013).

Anxiety Disorders
Contrary to what happens with mood disorders and psychosis, anxiety
disorders in parents are mainly associated with anxiety disorders in the offspring(transgenerational concordance) (Santvoort et al, 2015). The risk for developing

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IACAPAP Textbook of Child and Adolescent Mental Healthan anxiety disorder by offspring of parents with anxiety disorders is double that
in offspring of parents without anxiety (Leijdesdorff et al, 2017). In a recent
meta-analysis the risk ratio was estimated to be 1.76 (95 % CI=1.58-1.96) with aparticularly high risk for children of parents with panic disorder and generalized
anxiety disorder (Lawrence et al, 2019).

Personality Disorders and Substance Use DisorderHigh rates of mental disorders have been found in children of parents withpersonality disorders and substance use disorder though the majority of studies
have been conducted with respect to antisocial/dissocial and borderline personality
disorder (BPD). Children of parents with BPD show an increased risk for multiple
psychopathologies, including internalizing and externalizing disorders, emotional
dysregulation and insecure attachment patterns (Eyden et al, 2016). Compared
to children of mothers with other mental disorders, children of mothers with
BPD suffer from a greater number of mental disorders in general, specifically
ADHD, disruptive behavior disorders and BPD (Barnow et al, 2013; Weiss etal, 2016). The combination of major depressive disorder and BPD in parents
significantly increases the risk for major depression in the offspring. In a study
comparing children of parents with major depressive disorder only, and depression
with comorbid BPD showed a prevalence of 10 % of major depressive disorder inchildren in the first group and 45 % in the second (Abela et al, 2005).
Studies on personality disorders other than BPD are sparse but a significant
link between conduct/oppositional defiant disorder in children and antisocial/dissocial personality disorder in parents is established (Frick et al, 1992) See
Chapter D.3. A high-risk study conducted in Switzerland with children of parents
with alcohol or heroin dependence yielded a lifetime prevalence of mental disorders
in offspring of 63 % and 61 %, respectively (Vidal et al, 2012). Parental substancedependence was associated with multiple psychopathological outcomes in children,
such as mood and anxiety disorders, ADHD, and substance dependence. Thesefindings were replicated in Iran with children of parents dependent on opioids ormethamphetamine (Paravesh et al, 2015).

OTHER OUTCOMES IN COPMI
Physical Health
Physical health issues in COPMI have not been studied to the same extent
as mental health ones. Nevertheless, there are data indicating that parental mental
illness not only affects the psychological but also the physical health of the offspring(Santvoort et al, 2015). For example, a representative cohort study from Australia
supported a relationship between maternal depressive symptoms in early childhoodand childhood asthma (Giallo et al, 2015). A 20-year follow up study found thathaving depressed parents doubled the likelihood of physical health problems intheir children (Weissman et al, 2006b). An association between maternal mental
illness and atopic dermatitis has been consistently found (Letourneau et al, 2017).
The Avon Longitudinal Study of Parents and Children found that offspring of
mothers with postpartum depression exhibited increased sleep problems in lateadolescence (Taylor et al, 2017).

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IACAPAP Textbook of Child and Adolescent Mental HealthAcademic Performance
A variety of studies in several countries have consistently shown thatchildren of parents with mental health problems perform worse academically thantheir counterparts (Mechling, 2011; Berg et al, 2016; Ranning et al, 2018). Poor
academic achievement and other school related problems such as absenteeism andnot completing homework seem to be positively correlated with the time children
have to perform age-inappropriate responsibilities due to their parent’s illness(Cree, 2003). Beyond scholastic performance, an elevated rate of unemployment
was found in adult COPMI (Christoffersen & Soothill, 2003).

Parentification
Children and adolescents who have a parent with a mental disorder often
care and support their parents, both physically and emotionally. In some cases,
this may result in role-reversal, boundary distortion, and an inverted hierarchy.
This phenomenon has been described as “parentification” (Minuchin et al, 1967).
A number of studies have shown that children who experience parentification
are at an increased risk of showing psychopathology in adulthood. The effect ofparentification on mental health problems seems indirect via perceived stress (Van
Loon et al, 2015).

Other Adverse Consequences
Several other adverse consequences have been reported to be associated withparental mental illness (e.g., Christoffersen & Soothill, 2003; Gellatly et al, 2018;
Tabak et al, 2016), which further compound the problems such as:•Child maltreatment•

Neglect•

Family separation and foster care•

Lack of parent’s attention•

Stigma•Teenage pregnancy.

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In summary, children ofparents with a mental
disorder have about twice
the risk for any mental
disorder compared withchildren of parents withouta mental disorder. Further,risk for the developmentof the same disorder asthat present in the parent
is higher than for otherdisorders. Particularly highrates of mental disorders arefound in offspring of parents
with personality disorders
and substance misuse.
Mental illness in parents
does not only affect mental
health in their children but
is associated also to otheradverse outcomes such as
poor physical health andpoorer academic outcomes.

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IACAPAP Textbook of Child and Adolescent Mental Health

RISK AND PROTECTIVE FACTORS
Several risk and protective factors have the potential to either increase or
decrease the likelihood of the transgenerational transmission of mental illness,
which are important moderators or mediators. According to the developmental
model of transgenerational transmission (Hosman et al, 2014), child factors,
parent factors, and environmental factors can be distinguished. These factors may
interact with each other multiplying the effect (Collishaw et al, 2016). Surprisingly,
regardless of a number of publications on this topic, only a few studies report
empirical data on risk and protective factors for the transgenerational transmission(Goodman & Gotlib, 1999; Hosman et al, 2014).

Child Factors
Gender and age
A metanalysis of potential moderators for problem behavior in children of
depressed mothers yielded significant gender differences (Goodman et al, 2011).
Girls are more likely to show internalizing problems than boys, while there are no
gender differences with respect to externalizing problems. In general, it is assumed
that a parental mental illness has the highest influence on childhood mental healthin the early years (Hosman et al, 2014).
Temperament and attachment
A difficult temperament among offspring has been found to be associatedwith a higher risk of transgenerational transmission. For example, children
with one or more depressed parent were twice as likely to develop a depressive
disorder 20 years later if they had shown a difficult temperament in the early years(Bruder-Costello et al, 2007). However, a clear causal link could not be drawn.
The mediating role of attachment in this process has been deduced mainly fromtheoretical models and indirect empirical data. For example, it was found thatmaternal depression is associated with an increased rate of insecure attachment inoffspring and with an elevated risk for behavior problems (Cicchetti et al, 1998).
A mediating role has also been reported between attachment in fathers who abuse
alcohol and internalizing, externalizing and substance abuse behaviors in theiroffspring (Wlodarczyk et al, 2017).

Jane
Jane is an 8-year-old
girl living with her motherwho had been diagnosed
with bipolar disorder withpsychotic features
When Jane was five
years old, her mothertook her in a car andtried to kill herself andJane by crashing thecar. Jane knew what her
mother was trying to do
because her mother was
screaming that she would
do it. “Mom has a sickhead and I’m afraid herhead will kill her”. The
girl constantly observes
her mother, monitors her
expression, and worries
about her mother all thetime. In spite of her age,
Jane checks if her mothertakes the medicationsprescribed, if she attends
her appointments withthe psychiatrist, andattends to an inordinate
proportion of household
duties.

Cognition
Active coping strategies such as problem-solving, seeking social support, andsharing problems with parents were associated with fewer internalizing problems
in adolescents (Loon et al, 2015). No protective factors have been found forexternalizing problem behavior. A study found that a cognitive style characterized
by negative attributions or self-criticism seems to partially mediate the association
between parental borderline personality disorder and child depressive symptoms(Abela et al, 2005).
General cognitive factors may play a moderating role in the transmission ofmental disorders. As such, child risk-taking and poor working memory increase therelationship between maternal depression and internalizing problems in the child(Flouri et al, 2017). Poor working memory also had an effect on the relationshipbetween maternal depression and childhood conduct problems.

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IACAPAP Textbook of Child and Adolescent Mental HealthMunicipal Shelter (Städtisches Obdach). Kathe Kollwitz, 1926

Emotion regulation
Emotion regulation seems to influence the transgenerational transmissionof mental illness as well. Positive emotion regulation was reported to moderate therelationship between maternal depression and child internalizing symptoms (Silket al, 2006). There is also some evidence of an indirect effect—emotion regulation
might be a mediator between attachment, temperament and internalizing
symptoms in the offspring.
Emotion processing
Emotion processing—the ability to process stress and other extreme eventsand move past them—has been found to be connected with transgenerationaltransmission. In a large study, children’s reactions to their parent’s sad feelings
and their own depressive symptoms were assessed. Results indicated that children
who displayed emotional over-involvement or avoidance had elevated depressive
symptoms (Solantaus-Simula & Punamäki, 2002).
Attribution
A study from Nigeria assessed the influence of beliefs about mental disorders
in COPMI on their own depressive symptoms (Ola et al, 2015). Children who
believed that mental illness was contagious showed more depressive symptoms thanthose who did not share this belief. This was especially true for younger children.
At the same time, the belief that people with mental disorders are dangerous did
not contribute to their depressive symptoms.

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In summary, young age
and female gender, adifficult temperament,poor coping strategies,
emotion regulation andbeliefs about parental
mental illness, as well as
general cognitive skills
such as working memory
and emotion processing,have all been shown tomoderate and mediate
the transgenerationaltransmission of mental
illness. However, empiricalevidence is sparse andcausation cannot always beestablished.

9IACAPAP Textbook of Child and Adolescent Mental HealthParent Factors
ParentingMental illness in parents has been found to be associated with poor parenting(Hosman et al, 2014). For example, parents with social anxiety disorder showeda less positive affect and warmth, as well as more criticism and doubts about theirchildren’s competence when compared to parents without an anxiety disorder(Crosby Budinger et al, 2012). Mothers with borderline personality disorder were
found to have difficulty in correctly identifying their children’s emotional stateand be more overprotective than healthy mothers (Petfield et al, 2015). At thesame time, parents with mental illness experience more parenting stress, decreased
feelings of competence, and less satisfaction with respect to their role as a motheror father (Petfield et al, 2015). The majority of studies have found that negative
parenting styles may contribute to the transmission of mental disorders, while theabsence of positive parenting is less likely to do so (Wilson & Durbin, 2012).

Click on the image to watch
a family discuss how they
coped with the mother’smental illness (6:42)

Other negative parenting features that have been found to be associated withdecreased child mental health were high expressed emotions, decreased parental
monitoring, insensitivity, overprotection, hostility, and criticism (e.g., Beardslee etal, 2011; Loon et al, 2015).
Health status and availability of parents
The health status and availability of parents are hypothesized to play asignificant role in transgenerational transmission (Goodman & Gotlib, 1999;
Wlodarczyk et al, 2017). Research results indicate that lifetime prevalence ofmental illness in COPMI increases if both parents suffer from a mental disorder,
compared to when only one parent is affected (e.g., Dean et al, 2010; Hosman etal, 2014; McLaughlin et al, 2018; Vidal et al, 2012). Parenting status contributes
to transmission as well. For example, the risk for externalizing problems in childrenof depressed mothers was lower for children of two-parent families compared tothose from single-parent families (Goodman et al, 2011).
Disorder-related factors
A higher number of comorbid disorders, chronicity, and severity are
positively correlated with the prevalence of mental health problems in offspring(Beardslee et al, 2011; Johnson, 2018). A WHO survey concluded that thelikelihood of mental illness in COPMI increased from an odds ratio of 1.9 forchildren of mothers with one disorder to 3.2 for children of mothers with threeconcurrent disorders (McLaughlin et al, 2018). The same pattern was found formentally ill fathers. With respect to the time course of parental mental illness,onset of a parental depressive disorder before the age of 30 was associated with amuch higher relative risk (13.1) for depressive symptoms in COPMI than a later
onset (relative risk = 4.1) (Hosman et al, 2014). Of course, age of onset is highly
confounded by child age and sensitive periods of influence of a parental mental
illness. For example, the duration of exposure to active parental bipolar disorderin childhood is an important risk factor for the subsequent development of moodand non‐mood psychopathology in the offspring, particularly during the first two
years of life (Goodday et al, 2018).

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To conclude, parenting
capacity is affected
negatively by parental
mental illness. Negative
parenting styles inparticular are associatedwith transgenerationaltransmission. Disorderspecific characteristics suchas number of comorbid
conditions, chronicity, andseverity of the parent’s
disorder also increase risk.

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Environmental Factors
Disentangling the effects of genetic inheritance, environmental factors
and their interaction is a complex problem. Mental illness by itself is associatedwith higher levels of adverse environmental factors such as lower socioeconomic
status, more family conflict, less family cohesion, lower levels of social support,
and increased stress. Some of these contextual factors may have a moderating rolein the transmission of mental disorders while others do not seem to explain mental
illness in offspring independently from the parental mental illness (Cicchetti et al,
1998; Petfield et al, 2015).
Pre- and peri-natal factors may interact with genetics to influence the riskof mental disorders in offspring. A Finnish birth cohort study investigated theassociation between parental psychosis and potential risk factors for schizophrenia
and their interaction (Keskinen et al, 2013). The presence of any biologicalrisk factor (such as high birth weight, high maternal age) increased the risk ofschizophrenia significantly only among children of parents with psychosis, whereas
the presence of any psychosocial risk factor showed no interaction with parental
psychosis.
Poverty
Material deprivation is strongly associated with mental illness in general,and the same is true for their transgenerational transmission (Luciano et al,2014). Children of depressed mothers had an increased risk for internalizing andexternalizing problem behavior if they came from low income families comparedto those with middle or high income (Beardslee et al, 2011; Goodman et al, 2011).

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However, the effect varies globally with a higher impact in high- and upper-middle
income countries (McLaughlin et al, 2018).
Social support
Support from people outside the core family seems to be a protective factor(Hosman et al, 2014; Wlodarczyk et al, 2017). This support can be provided byany healthy adult such as grandparents, teachers, or neighbors, who assume therole of “significant other” by serving the child as a stable and healthy support
person and giving attention when the ill parent is not available. Support for theill parent has been shown in a longitudinal study to decrease transgenerationaltransmission (Lee et al, 2006). Conversely, the social environment can be a risk
factor, as when COPMI experience stigmatization or social exclusion.

INTERVENTION
To meet the specific needs of COPMI, various interventions have beendeveloped and there is some empirical support for the effectiveness of prevention,even though studies have so far shown mixed results (e.g., Bee et al, 2014; Cuijpers
et al, 2014; Kersten-Alvarez et al, 2010; Kersten-Alvarez et al, 2011). Overall,treatment of the ill parents have been associated with improved outcomes in theiroffspring, although there are few studies that target the same symptoms in bothchild and parent (Cuijpers et al, 2014; Schneider et al, 2013).

In summary, parental mental
illness is associated withadverse environmental
circumstances. While
poverty adds to the risk
for mental illness in
COPMI, social support
for the ill parent and thechild decreases the risk.
Family characteristics also
seem to play a crucial rolein the transgenerationaltransmission. Childrenof couples who are both
affected by mental illness
and those from single-parent
families are at an increased
risk.

There are several meta-analyses of programs for COPMI evaluating
heterogeneous interventions and showing limited efficacy (e.g., Cuijpers etal, 2014; Siegenthaler et al, 2012). A subsequent, more comprehensive metaanalysis included 96 randomized controlled trials with 50 independent samples ofchildren of parents with a diagnosed mental disorder (current or previous), which
reported either children’s psychopathology or that had observations of motherinfant interaction (Thanhäuser et al, 2017). For both mother-infant interaction
interventions and for interventions for children and adolescents the benefits weregenerally small.

Treatment Approaches
Treatment of the ill parent
Longitudinal studies on parental anxiety and depression show heterogeneous
effects of parent treatment on children’s symptoms. For example, a six-year
prospective study on the effects of treatment of parents with panic disorder
showed a reduction in children’s anxiety symptoms. Other studies (e.g., STAR*D;
Wickramaratne et al, 2011) showed that children of mothers whose depression
had remitted early had fewer externalizing problems.
Family Talk Intervention
One of the most widely used programs for COPMI is the Family Talk
Intervention (FTI). This is a whole-family approach that seeks to enhance childresilience and communication within the family (Beardslee et al, 1997a; Beardslee
et al, 1997b). One of its main goals is to enhance children’s knowledge about theparental disorder, which seems to improve children’s outcomes (Punamäki et al,

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IACAPAP Textbook of Child and Adolescent Mental Health2013; Solantaus et al, 2010). Apart from reducing parental disorder symptoms,
this lessens children’s feelings of guilt, anger, and shame. Core elements of FTI are:
•
•
•
•
•

Assessment of all family members
Psycho-education about the parent’s disorder
Connecting the family history to psycho-education
Reduction of guilt and shame in children
Enhancement of children’s support.

FTI consists of eight sessions with potential follow-up sessions if needed.
The FTI program has been adapted in a variety of countries, especially in Northern
Europe (e.g., Beardslee & Röhrle, 2009; Pihkala et al, 2011; Punamäki et al, 2013;
Solantaus et al, 2010).

Click on the image to watcha brief clip highlighting that aparent mental disorder canhave a positive impact in thelong term (3:49).

Support groups
Specific support groups for COPMI have been shown to be of little benefit so far.

CHALLENGES FOR PREVENTION AND
INTERVENTION
Low utilization of services to support COPMI and their families is achallenge. A study from the UK assessing children of parents with depression(Potter et al, 2012) found that only 37 % of the children already suffering froma mental illness were in contact with a service. Even one third of those children
identified as suicidal or who showed self-harming behaviors were not receiving any
service.
Although parents’ therapists could play a decisive role, several studies indicatethat therapists manly focus on the needs of their adult patients. For example, a
medical record study in New Zealand of adult patients seeking help from a crisis
assessment team reported that less than 50 % of these records included information
about the situation of the children (Pfeiffenberger et al, 2014). A specific action
plan to enhance the child’s well-being was only present in 6 %. Comparable results
were found in a Norwegian study (Lauritzen et al, 2014). These results show thatenhancing psychotherapist’s awareness and knowledge about these issues is neededin order to provide COPMI with the necessary information and with adequate
support (Leijdesdorff et al, 2017).

Click on the image to accessthe COPMI Australianwebsite. This site has alarge number of resources,
many of them translated into
languages other than English

ONGOING RANDOMIZED CONTROLLED TRIALSRegrettably, there is an overall lack of effective interventions for COPMI,
though recently some higher quality studies are in progress. We list three of these.
Interested readers may find the details in the references provided.
The first is the Danish High Risk and Resilience Study (VIA 7 & 11). Thisis a prospective study targeting children of parents with schizophrenia or bipolar
disorder by identifying risk profiles through a comprehensive test battery, andcomparing the results to those of children with healthy parents (Thorup et al,
2018a; Thorup et al, 2018b).

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The second is the COMPARE study, which seeks to examine the effects
on children of parental psychotherapy compared with parental psychotherapy inconjunction with a parenting program—targeting the fact that parenting skills
have been shown to be reduced in parents with a mental illness. The assumption isthat the addition of a parenting program will lead to incremental effects above andbeyond treatment of parents alone (Christiansen et al, 2019b; Stracke et al, 2019).

Click on the image for awebinar by Holly Swartz
MD from the Universityof Pittsburgh describinga research study about
the impact on school age
children of psychologicalinterventions for maternal
depression (59:23)

The third study (“The Village”), an implementation and dissemination
study, focuses on the identification of COPMI within the adult mental healthsystem and the facilitation of collaborative care highlighting the “child’s voice” as afocus (Christiansen et al, 2019a).
Other ongoing studies worth mentioning include:•••

A study in the Netherlands on the effects of an internet-based preventive
group treatment (Kopstoring). An aspect of this study is that it alsoseeks to examine the cost-effectiveness of the intervention (Woolderink
et al, 2010).
In the UK, a group intervention (Young SMILES) for COPMI aged
six to 16 years and their parents is being evaluated in a feasibility trial(Gellatly et al, 2018; 2019).
An international group is examining a modified form of the Child Talk
Intervention (Child Talk +) (Reedtz et al, 2019).

ARE THERE PRACTICAL STEPS THAT CLINICIANSCAN TAKE TO HELP THESE CHILDREN?
While the data available is compelling, the issues are very complex andthe evidence to guide clinical practice scarce. Thus, clinicians may become
overwhelmed by the data, confused, and give up trying to do anything. Are there
simple, practical measures that clinicians can take even in settings with limited
resources?
A basic first step is to identify children of parents with a mental disorder. For
example, asking about whether there are children living at home when diagnosing
them in the clinic or when admitting a patient to hospital and, if so, providing
appropriate support not only for the parent but also for the child and other family
members. The Family Talk Intervention (FTI) is the most widely used standardisedintervention, which has been adapted in several countries and languages. COPMI
support groups, however, have shown limited benefit.
Secondly, open communication within and outside the family about themental illness of a parent is crucial in order to demystify the problem and ensuringthat children acquire adequate and realistic knowledge about the disorder. The
involvement of a non-affected parent, other adults that may provide social support
or institutional assistance may help to stabilize the family and serve the special
needs of the child. Here, education about potential fears of negative consequences
and stigma may encourage parents to utilize services to support their children.
Finally, screening of the child’s mental health status by a professional isadvisable because the risk to develop a mental disorder is high and early intervention
is associated with greater benefit.

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There is currently a focus on new ways of establishing collaborative care(e.g., by involving other health professionals, education and welfare staff), essential
when dealing with these complex, multi-system issues. In this line, detecting andtreating anxious and depressed mothers in paediatric and primary care settings—
and not just in specialist mental health services—is essential since these areeminently treatable conditions and their improvement is likely to reduce morbidity
in the children in the sort and long term.

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