SCIE Research briefing 23: Stress and resilience factors in parents with mental health problems and their children

By Lester Parrott, Gaby Jacobs and Diane Roberts

Published March 2008

Introduction

This briefing focuses on factors contributing to either stress or resilience in families where one or both parents have mental health problems. It considers the position of parents and children focusing upon issues of stress or resilience arising from individual and ‘informal’ sources. While recognising the role that services have in mediating either stress or resilience, the briefing does not consider service interventions or evaluations, as these are the subject of a SCIE systematic review to be published separately.

What is the issue?

For the purposes of this briefing, stress refers to a state of mental, emotional, or other strain, (1) while resilience refers to the ability to withstand or recover quickly from difficulties. (2) In identifying these characteristics it is also important to understand that stress and resilience are potentially complementary. Stress and resilience can be characteristics of individuals, families and communities, and the briefing therefore discusses interdependent factors such as community support.

At any one time, one in five adults in the UK will be experiencing mental health problems, with approximately 30 to 50 per cent being parents. (3) As a result, one estimate suggests that some two million children live in a household where at least one parent has a mental health problem. (3) Accordingly, current approaches to social inclusion have identified the needs of parents with mental health problems as a key concern for social policy. (4) (5) However, families affected by mental health problems vary in their capacity to cope with the difficulties that arise from this. In this context, research-based knowledge about both stress and resilience factors for parents with mental health problems and their children can help health and social care professionals to make more appropriate assessments and to develop appropriate services.

Why is it important?

Changes in policy towards people with mental health problems over the past 20 years mean that more adults who have mental health problems now live within the community. Moreover, those who have recovered from mental health problems are increasingly voicing their concerns for improvements in mental health services that will enhance community inclusion. (6)

For children, changing attitudes towards child care practice have also meant an increased emphasis upon either keeping children with their birth parents, or maintaining appropriate contact with them. (7) As a result of these policy changes, more children will be living with a parent with a mental health problem and more parents with a mental health problem will be experiencing the challenges of parenting their children. These trends are not peculiar to the UK, but are also evident in Europe and the USA. (8)

What does the research show?

Much research concerning families with mental health problems focuses upon individual factors, for example, individual characteristics of personality which, although important, may overlook individuals’ social and cultural contexts. This is highlighted by a review of research considering the uniqueness of cultural pathways to resilience. (9) In addition, the individualised nature of stress and resilience research has been challenged by some researchers who suggest that when assessing a family’s resilience, the unit of analysis should be the family itself, rather than the individual’s perceptions within the family unit. (2) However, a recent exercise by SCIE, (10) examining the literature on parental mental health problems in families, recognises the limitations in the current state of research, identifying:

• the lack of research upon males within families
• a predominance of research material focusing upon depression
• a limited recognition of the child’s perspective within the family.

Stress

A review of individuals’ interactions with their social environment noted that inequality and poverty were significant stressors in families with mental health problems. (3) It also noted that the cumulative effect of such stressors at the individual and social level required careful analysis to ascertain their relative impacts. A further study (11) identified three sets of mediating factors impacting upon family members:

• biological (in utero) influences on foetal development
• relational influences such as mother-child discipline, exposure to negative behaviours, child attachment, and modelling behaviour by parents
• factors that indirectly affect maternal and child functioning such as income and a lack of social resources.

Poverty

Relationships between parent and child are therefore situated within a series of ever-widening systems, moving from the child through to the family system and into the wider cultural and socio-economic system. (12) One study highlights, for example, the contribution that a parent’s mental health makes to children’s poverty (3) and shows that less than one quarter of adults with long-term mental health problems are in work. They have the highest rate of unemployment among people classified as disabled. In addition, they will also experience what Gould refers to as ‘inadequate employment’ characterised by periods of absence from work and, thus, directly affecting their income and career prospects. Consequently, approximately 198,000 parents, responsible for the care of an estimated 368,000 children, rely on state social security benefits. The stresses of poverty are therefore profound and mental health problems tend to coexist with low income, social disadvantage and low social support. (13)

Community

Similarly, a lack of community supports also impacts upon families and children. A study of black children’s experiences of caring found an additional burden of care where there was a lack of culturally appropriate services. (14) It also found that these children had less formal contact with school and less contact with friends. Schooling can provide a complementary secure base that improves resilience; a reduction in contact can lead to significant stress by reducing children’s opportunities to develop social networks and self-esteem. (15) Wider research on ‘young carers’ concurs with this view, noting the potential for increased isolation and impairment of educational prospects. (16)

Parental mental health

Research also emphasises the dynamic interplay between maternal depression and child distress, thus the mutual stresses experienced by parents and children have a transactional effect. (17) The effect is cumulative: maternal depression may result in parenting which is either too intrusive or withdrawn, creating a further cycle of disruptive behaviour by the child. One of the major stressors for families where this transactional effect can be identified is that of loss, including the complex loss created by mental health problems because the person who has been ‘lost’ is still present in the family. (18) This study (18) also shows how such complexity can extend into areas of conflict. For example, families may feel anger towards the person with a mental health problem and subsequently experience feelings of guilt, which impairs relationships but also inhibits the process of ‘bereavement’. Given the importance of secure attachments in promoting and maintaining resilience, the experience of being parented or living with a person who no longer interacts with, and relates to, family members in recognised ways, can be a significant stressor for family members.

Research in the Republic of Ireland has compared children with one parent with schizophrenia, with those whose parents have no mental health problems. (19) The children of a parent with schizophrenia experienced more psychiatric disturbance and more problems at school, spending more time at home and becoming socially isolated. Experiencing a parent’s schizophrenic behaviour brought immediate stress: children became frightened of their parent’s behaviour but also feared for the long term assuming they might inherit the illness. Other research shows that children may be at risk of adopting a parent’s delusional state, which increases the chance of physical and emotional danger. (20)

Depression among mothers has also been found to lead to children experiencing problems of attachment and bonding with their fathers, even when the father has no mental health problems. (21) The presence of depression in either parent has also been shown to increase father-child conflict which, in turn, can create developmental problems for children. (22) Indeed, the risk of depression among children whose fathers had depression is 45 per cent greater than where fathers had no identified depression. (23) It also identified gender differences in how depression is expressed, with males more likely to withdraw from social situations, and to become more irritable and cynical. This review also noted a number of studies which concluded that depression among fathers had negative impacts upon communication within the family. One study further noted that negativity within families was significantly more prevalent with paternal rather than maternal depression. (24)

Resilience

Resilience research has itself moved through a number of phases. (9) Initially, individual factors were highlighted focusing, for example, upon temperament and wellbeing. A second phase in the research literature focused upon relations within families, while more recent research emphasises ecological dimensions and highlights the interactions between the individual and their social environment. In addition, some research now acknowledges the role of culture, so that resilience is not only an individual/environmental phenomenon but a cultural accomplishment. (9)

The values, beliefs and everyday practices which are associated with coping are shaped by culture. An understanding of specific cultural beliefs and practices that can contribute to building resilience within individuals and families is therefore significant. These beliefs may also challenge professionals’ own cultural and professional values; therefore such beliefs and practices need to be assessed for their relative contribution in either building resilience or frustrating it. For example, some US research suggests that traditional, more authoritarian styles of parenting, may be more appropriate for some children from Asian or African-American backgrounds. (25)

Other research shows that resilience has both learning and therapeutic elements which may assist individuals to not only cope with particular stressful life events, but also enable their emotional development as individuals. It is also variable, as people can be resilient in some contexts but find difficulties when the context and the nature of the risks presented change. (26) The balance of research thus indicates that resilience is not extraordinary but is present in all human beings. Professionals who assess only for problems within families may overlook existing strengths and coping capacities. Behaviour that exhibits resilience, such as maintaining social networks or continuing with interests outside the family, can be misinterpreted as avoidance or symptomatic of a pathological response to loss. (27) Most parents with mental health problems parent their children effectively, (28) and most children suffer few, if any, adverse effects from their parents’ problems. (29) Thus, the variety of ways in which people respond and cope with such challenges must be carefully assessed.

Understanding the importance of resilience

Key building blocks for developing resilience in children and parents come from a sense of security, a recognition of self-worth and the experience of control over one’s immediate environment. (30) (15) Gilligan’s work is instructive here; she argues that understanding the importance of resilience can refocus a professional’s intervention towards an outcomes-based approach that accounts for individuals’ and families’ strengths as well as their needs. (30) The importance then of a secure base for individuals, and the chance to experience multiple social roles beyond that of parent or child, is essential in building resilience. The foundations built through this security can enable children to explore the wider social world where friendships can be made and talents and interests pursued. (15) Recognising the coping capacities inherent within children and parents is therefore an important prerequisite in building upon the strengths of individuals and identifying appropriate interventions.

Parental bonding

A study of the impact of maternal depressive symptoms upon homeless children’s mental health and behaviour showed that, although the impact on behaviour was higher than for the general population of children, nearly three quarters had no behaviour problems. (31) (32) (33) The robustness of children to the pressure of their parents’ mental health has been confirmed by a study of children with parents hospitalised for depression. (34) Children of depressed patients, and a control group of children of surgical patients, were compared in a 25-year follow-up study on measures of psychiatric illness, personality, marital and family relationships. The researchers found little difference between the two groups in terms of rates of psychiatric morbidity and the quality of intimate relationships. (34) In addition, the research confirmed an association between parental depression, and anxiety and substance abuse disorders in their children. The children of depressed mothers also experienced problematic relationships with their fathers.

Maternal and paternal bonding have also been linked to a child’s coping strategies with a lack of effective attachments, particularly with the mother, leading to poor coping strategies and depressive symptoms. (35) Moreover, individuals who experience positive maternal bonding are more likely to endorse social support-seeking as a coping strategy. Maternal bonding and positive parenting involve:

• love and affection
• setting boundaries
• listening and praise
• apologising when making a mistake
• letting go and renegotiating the boundaries as the child matures (NSPCC).

It is therefore possible that maternal bonding provides the foundation for resilience; this is particularly important for children in two-parent families where one parent has a mental health problem. In this situation, the input of the well parent is crucial in providing effective and positive parenting through close support and relationship building. (29) (36) Where this ability has become fractured, the role of community support and services in enhancing and building resilience is crucial. This is particularly important for single parents: evidence from Canada shows that single mothers experience significantly higher mental distress than their partnered counterparts. (37) Research also showed that 21 per cent of lone parents, but only one per cent of married parents, fell into the lowest income category, and that parental psychological distress was almost twice as common among lone (30 per cent) as married parents (16 per cent). (38)

Social support

Having social support is an important contributor to resilience, and the extent to which people deal with stressors is in proportion to the amount of social support received. (39) This can be as simple as practical assistance with basic tasks like shopping, or the receipt of more emotionally-based support which can convey empathy and positive regard. (40) The quality of support, however, varies within and between family members and therefore variations in the closeness between family members needs to be recognised. Thus, effective support is reciprocal, (41) in that help received in one situation can be returned in another. Those who have been stigmatised by the label mental illness can thus be appreciated for the support they can give to others. (41)

Control and optimism

Optimism and perceived control over one’s life are also significant factors in enabling individuals to engage with protective processes. (27) Optimism refers to the expectation that a person will experience good outcomes in the future, while perceived control involves the belief that one can be effective in influencing events and conditions in one’s own environment. Thus, optimists use constructive coping strategies that appear to foster greater proactive responses to stressful situations. People who perceive their outcomes as being more amenable to their own agency are at less risk of depression, especially after stressful events, suggesting that those people make more positive steps to overcome these stressors. (42) A key component in promoting optimism is the level of knowledge and understanding about the parent’s mental illness among family members. Enabling children to understand the parent’s illness appears to enhance their resilience. (43) (44) Research into children’s perspectives of their parents’ mental illness has, however, been largely absent from the literature to date. (45)

It is also possible to identify key resilience factors that enable children to resist over-identification with their parent’s illness (46) and, accordingly, to build on these and develop positive interventions for these children. (47) Thus, a review of individual resilience factors emphasises the importance of positive views that the child has of his/her own identity. (44) In contributing to our understanding of these processes, there are calls for more qualitative research that include the narrative accounts of parents and children. Narratives, it is argued, uncover and de-stigmatise the presence of mental health problems in families, uncovering new insights which can generate further research. (48)

Recognising service users’ narrative accounts, for example, has highlighted the significance of service user-led groups and self-help groups. (49) The supportive environments fostered by such groups can promote strength within the group itself and help foster self-determination which can enhance greater control for the person with a mental health problem. The importance of social networks linking service users, leading to a positive sense of self and expectations of change, is also identified. (50) A study comparing people with mental health problems who belonged to a self-help group with those who did not found a significant decrease in the number of admissions and length of stay in hospital and increased satisfaction with life in the community for the self help group, in comparison with the control group. (51) A study of mental health consumer-run organisations in Canada also recognised the potentially positive effect of such membership, finding that resilience-building factors included increased self-esteem and a supportive social network. (52)

Gaps in the research

Research related to the cultural context of stress and resilience is limited in both the US and the UK, and remains an area to be more thoroughly investigated. (53) There is also little research in relation to the attachment and transactional effects within families that lead to increased resilience, though there are indications that suggest strong parental bonding leads to increased self-esteem, enabling individuals to seek and engage with support systems. (35) Developing this theme further, the absence of fathers in research suggests that there is much work to be done in investigating the importance of their role within families experiencing mental health problems. Finally, a greater emphasis on mental health problems other than depression needs to be developed, so that the impact on families of conditions such as schizophrenia can be assessed. (10)

Implications from the research

For organisations

The research clearly indicates that stress (and resilience) within families where parents have mental health problems can arise in various contexts. Service organisations therefore need to take a multi-faceted and multi-level approach to building resilience through the provision of effective support for individuals, families and communities. (54) Recent developments in child and adolescent mental health services (CAMHS) identify the need for effective partnerships to be developed encompassing both children and their parents. (55) (56) In practical terms, overall effectiveness in service delivery involves a multi-agency approach that brings together CAMHS with adult mental health and children’s services to surmount organisational barriers and deliver partnership working. This also needs to be coupled with early intervention and aggressive outreach, and there are many useful examples to be found within children’s and adolescent services. (57) In order to be effective, research also shows that services promoting resilience will need to recognise the social and cultural contexts in which such resilience is expressed. (9) This is particularly relevant where the needs of different groups have been overlooked, for example in terms of gender and ethnicity.

For practitioners

In identifying stress and resilience factors for people with mental health problems, the proper assessment of such factors plays a crucial role in meeting service user need. Official guidance on risk assessment58 concurs by suggesting that an assessment of risk should not only take into account stress factors, but also strength and resilience. Much supportive work is now provided by the independent sector and this should also be mobilised in order to promote the resilience of service users. (59) (60) However, despite many efforts to ensure the coordination of services, there are a number of issues and questions practitioners should identify and address in providing effective support. (61) Research by Slack and Webber (54) shows the reluctance of some adult mental health professionals to take a whole-family approach feeling, in particular, that child care issues are not their responsibility. Practitioners are therefore advised to read the National Social Inclusion Programme (NSIP) (62) guidance, which asks:

• Is someone in the family assuming a care-giving role?
• What are the caring practices evident in the family?
• If care giving is present, is the caregiver enabled to understand their role in relation to their own needs?
• Are social networks sufficient and appropriate?

It emphasises the need to work in partnership with families.

In addition, Appleby (63) provides some excellent examples of models of good practice describing many innovative ways of working in relation to CAMHS.

For service users and carers

There is evidence to show that the ‘voices’ of individual service users and carers, especially children’s voices, have been largely ignored. (45) In listening to service users, recognition that resilience is present within families should encourage the demand for assessments and services to recognise, build upon and maintain the strengths of service users. Allied to this would be assessments identifying those strengths in the wider community that can facilitate access for support and guidance. (64) The White Paper Our health, our care, our say (65) places great emphasis on wanting to make citizens’ needs central to the development of health and community services. It thus provides an opportunity for service users and carers to make their voices heard and call the Government to account. In recognising the claims of service users and carers, the Government planned to introduce a pilot scheme during 2007/08 in ten areas across the country. (66) It is claimed this will develop more local support networks and increase the number of individual talk-based therapies available. (67) (68)

For the policy community

The policy community will need to consider how the interface between child and adult mental health services is managed and developed in order to prevent both children’s and adults’ needs falling between gaps in services. Greater attention needs to be given to the needs of all family members, and the absence of fathers from the research literature (69) suggests a more positive policy response in this area is required. In widening the policy response, however, the role of the well parent for maintaining the coherence of the family becomes crucial. Where there is a single parent then the importance of mobilising community and professional support is also vital. The research also indicates a need for a greater focus upon provision that can reduce the experience of social isolation by, for example, maintaining levels of employment. (3)

To recognise the nature of stress and promote resilience within families where one or both parents have mental health problems, the significant contribution of community support needs to be recognised. Developing policy responses to the needs of minority ethnic groups in the UK is one area already recognised by Government. (70)

The quality of mental health care for BME communities in England is not acceptable. To be blunt, services are discriminating in a way that is arguably both unethical and unlawful. Communities feel alienated from NHS services and many are deeply mistrustful of them. This fuels a vicious circle of fear that deters people from seeking help early in their illness. Rosie Winterton MP, Minister of State for Health Services, 2006

The recent decision by the Department of Health to appoint local authority community development workers for black and ethnic minorities is one response to this situation. Final guidance on the role of such community workers has now been published which outlines best practice and gives useful case examples from existing practice. (71) The acknowledged positive role played by formal and informal community support networks also suggests that policy needs to develop such key resources for all service users. (67) (68) There is still much work to be done to ensure effective CAMHS services are established across the country, and the policy community must remain vigilant in ensuring the effectiveness of services for parents and their children with mental health needs. (57) (63) (54)