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Developmental Risks in Children of Mentally Ill Parents

If parents are mentally ill, this affects the psychological development of the children. Christiane Deneke explains what options pediatricians have for early detection and intervention.

1.5-3 million children and adolescents in Germany are temporarily, recurrently or permanently affected by a parental mental illness [1]. These children are at high risk of development [2, 3]; around a third of them will develop chronic and a third temporary mental disorders or illnesses. This article describes the stress caused by parental mental illnesses and their effects on the mental development of children. Because of its frequency and the preventive effect of early interventions, postpartum depression is discussed in more detail. Which indications of parental mental illness can be noticed in pediatric practice and which possible courses of action arise are to be discussed.

Disease risks

The disease risk is complex: the genetic-biological vulnerability, the increased psychosocial burden on most affected families and the burden of parental contact with children that is impaired due to the disease all contribute to this.

Genetic risk

The probability of developing schizophrenia is 10 to 13 times higher for a child with one schizophrenic parent; if both parents are affected, it is 40 times higher. If one of the parents has an affective disorder, the children develop an affective disorder (major depression, bipolar disorder) around twice as often as the normal population, and the disorder begins earlier, often in adolescence. We also find other mental illnesses in children of parents with schizophrenia or affective disorders. In addition, the children of mentally ill parents develop unspecific abnormalities or disorders such as extraversive and introversive disorders, emotional, cognitive and learning problems in 40-60% of cases. We find the worst developmental conditions in children of parents with borderline and antisocial personality disorders, especially when violence or addiction play a role. Whether an affected child develops a disorder depends only in part on the genetic load; on the other hand - according to the vulnerability-stress model - the severity and chronicity of the parental illness, the psychosocial environmental conditions, the quality of relationships and the coping with the illness in the family all play a role decisive triggering or protective role.

Psychosocial Stress

We find these more common in families with mentally ill parents: isolation, lack of social support, often single parents (mostly the sick mother) or unsteady, conflict-ridden partnerships, poverty, unemployment, poor education. The likelihood of neglect, mistreatment or sexual abuse is increased many times over in such precarious living conditions.

Age-specific peculiarities in dealing with the children

The ability of sick parents to be sensitive to their children and to deal appropriately with their needs for care on the one hand, and support for their interest in the outside world on the other hand, is in most cases temporarily or permanently limited.

This is particularly drastic in the Infancy and toddler age, since the quality of the interaction shapes the whole developing self of the child. A baby who experiences to be important and lovable will develop completely differently than one who goes unnoticed with all its efforts to get an emotional response from the mother or father. It will react differently again if it is repeatedly misinterpreted, if its crying is perceived as an aggressive act, or if it is treated as if it were an object without its own will or feeling. Therefore, the observation and treatment of the interaction between mentally ill parents and their babies is the most important therapeutic and preventive intervention, because - this is a result of the Mannheim risk child study - a persistent disturbance of the parent-infant interaction predicts a later psychopathological development of the child [4].

The early interaction experiences are also critical to the development of the bond. Sensitive parents can adequately support the child in its physiological, emotional and behavioral regulation, provide warmth and security and encourage exploration and learning - the basis for a secure bond, which in turn lays the basis for positive psychological development. Mentally ill parents are temporarily or permanently restricted in their ability to turn to the child with empathy and sensitivity. Correspondingly, we often find insecure and highly insecure-disorganized attachments in children of mentally ill mothers, whereby in addition to reduced sensitivity, the severity and chronicity of the disease, comorbidity, maternal attachment style and trauma in the mother's history play a role.

in the Kindergarten age Mentally ill parents can fearfully impede the need for exploration and motoric conquest of the environment or inattentively expose the children to all possible dangers, there can be problems with setting limits, defiance and own will can be misunderstood as aggression, the linguistic development of the children and the connection Social contacts can be hindered: fearfully adapted, sociophobic or hyperactive rampant behavior of the child can be the result. Even at this age, children feel responsible and guilty when their parents are not doing well. Confusion and fear due to the incomprehensible behavior of the parents affect the children especially when there are no other mentally healthy caregivers available.

in the Elementary school age parents are asked as role models, mediators of a realistic worldview and supporters in the acquisition of skills, which can be made very difficult by pathological withdrawal. This is also where shame and anger set in when the parents' deficits in comparison with others become clear. But since the children also adhere to the taboo on talking about the disease and are afraid to reveal something of their fears and worries, they are caught in conflicts of loyalty and quite lonely if there are no understanding third parties.

In the adolescence it is about the development of one's own personality and sexuality and the detachment from the parental home, which means fighting against the parents. Adolescent children of mentally ill parents find it difficult to separate themselves, usually they remain too tied up by the clinging need of the parents and the concern for them.

Parentification, i.e. the child taking on the role of a parent, is usually defined by the child's specific caring tasks for the sick parent and for siblings. But babies can already be parentified, for example by trying to ensure that the parents are not sad through distraction and cheerful expressions [1]. Even small children can give empathic comfort and help. Preschoolers have the opportunity to pretend to be unencumbered so as not to worry their parents. These behavioral possibilities - and the worries and fears about the parents - mean a mental parentification long before the assumption of specific functions begins. Such adaptations lead to disharmonious developments: the children mature prematurely, their childlike needs for support, play and contact with their peers are neglected. That means, even the "conspicuously inconspicuous", caring and over-conforming children need our attention.

Postpartum Depression

10-15% of women in western industrialized countries develop postpartum depression after having a child (more often the first child). In risk groups (migrants, young, single, poorly educated and abused women) the frequency is 35-50%. Further risk factors are: family or personal history of depression, depression during pregnancy, baby blues, exhaustion and exposure to a "difficult" baby. The depression occurs mainly in the first 3 months, but also in the course of the first year postpartum. The symptoms correspond to those of depression at other times in life: anhedonia, restlessness, exhaustion, all kinds of physical symptoms. However, the thoughts are concentrated on the baby and being a mother (fears of harming the child, in over 20% compulsive thoughts of harming the child, tormenting ideas of being a bad mother). The depressive emptiness is particularly serious when it also affects the relationship with the child: the mother perceives her child as alien and indifferent, the bonding (the spontaneous love relationship with the child that develops in the first moments of being together) is disturbed. The risk of suicide, otherwise lower for young mothers than usual in life, is 70 times higher, and there is a risk of extended suicide.

The interaction

In most cases the interaction is impaired. For the most part, sensitivity and responsiveness are reduced, responses to children's signals are delayed or absent and are rarely felt and appropriate to the baby's needs. There is less eye, voice and body contact, it becomes clear that the mother cannot enjoy her child, is tense and in a negative mood, experiences motherhood as a frightening, excessive burden and her child as a problem. A smaller part of the mothers is fearfully agitated, overly concerned and rather intrusive (aggressive) in dealing with them. These are very anxious depression or comorbid anxiety disorders. (Postpartum anxiety disorders are about as common as postpartum depression, often along with them). When dealing with the baby, these mothers are extremely tense, overprotective, restrictive, they do not leave the child to initiative, but rather control the interaction and therefore ignore the child's signals.

Effects of impaired interaction on the baby's self-esteem and development

Different interaction patterns were observed in a parent-baby day clinic [6]. Particularly problematic is such a greatly reduced responsiveness that the mother hardly reacts to signals from the child, and only with a delay. Then the child will withdraw, be passively withdrawn, emotionally empty and disinterested in the world around them. If a second, sensitive caregiver is missing, after 3 months the child appears just as depressed and withdrawn as its mother and remains behind in its development [7]. If a mother who is not very responsive reacts selectively to increased positive signals from the baby, the baby will persistently and positively strive for her attention and will develop into "mother's sunshine" early on, i.e. be parentified early on. Such developments are socially rewarded; the fact that those affected suppress negative impulses and do not develop a part of themselves can go unnoticed for a lifetime. If a less responsive mother does not react to the positive efforts, but then selectively to the baby's negative impulses (whining, screaming), the child can develop into a "pain in the ass", an eternally dissatisfied, bad-tempered child; negative interaction circles shape the relationship in the long term and often lead to counseling or treatment at an early age. The fearful, intrusive manner of dealing with them leads the baby to withdraw; if it is not allowed to do so, it protests and defends itself. Later power struggles can result, but in most cases the child takes on the mother's fears, explores less and eschews new situations and social contacts.

Developmental abnormalities

Developmental abnormalities in children of postpartum depressed mothers have been found in a number of studies from infancy to school age [8, 9]. These are attention deficits, lower IQ scores, increased irritability, lack of interest, reluctance to play, and a dysphoric mood. If there are additional risk burdens, the interaction disorder tends to become chronic even after the depressive symptoms have subsided, and in the children uncharacteristic abnormalities in the emotional and social area such as the frequent expansive disorders or increased anxiety and withdrawal, learning disorders, low self-esteem, low social levels Competencies.

Possibilities for prevention by paediatricians

What warning symptoms can be observed in the pediatric practice?

Almost all children are presented for the first screening examinations, and most of these examinations are carried out by paediatricians. Therefore, there are very special opportunities for prevention through early detection of risks in the field of psychological development. In order to take advantage of these prevention options, it is necessary to pay the same attention to the behavior of the child and the interaction with the primary caregiver as to the physical findings during early diagnosis examinations and other occasions for a presentation in pediatric practice. Table 1 summarizes which abnormalities are significant or even to be assessed as alarm signals.

What should I do?

In the Infancy and toddlerhood In addition to the treatment of the maternal disease, observation and treatment of the interaction is essential. Supportive measures such as help in the household and in dealing with the baby as well as parent-infant counseling through early help are useful. Partly taking care of the baby outside of the family (by child minders, crèches, sponsored families) relieves the mother and means an alternative relationship experience for the child. Joint (partial) inpatient treatment of mother and child may be necessary in more severe cases, as well as admission of both to a residential facility.

For Families with older children In addition to supporting measures such as socio-educational family help, family counseling, prevention groups for children and young people and sponsored families are particularly suitable. In hospital treatment, the children should definitely be included, they experience the worrying symptoms most directly and often enough remain without information because they want to be spared. If the best interests of the child are at risk, the child must be placed outside the family at any age. Table 2 provides an overview of the required measures.

Essential for practice. . .
  • Mental illnesses in the parents are associated with a high development risk for the children.
  • Because of its frequency, postpartum depression plays a particularly important role; In the western industrialized countries 10-15% of all mothers are affected, in risk populations the frequency is even 35-50%.
  • Early detection and intervention are crucial, so abnormalities in the young child's behavior and interaction with caregivers require the same medical attention as physical symptoms.

1. Deneke C (2009) Children of mentally ill parents. In: Schlack HG, Thyen U, von Kries R (Hrsg) Sozialpädiatrie. Springer, Heidelberg, 396-403
2. Mattejat F, Remschmidt H (2008) Children of mentally ill parents. Dt Ärztebl 105: 413 - 418
3. Wiegand-Grefe S, Geers P, Petermann F (2011) Developmental Risks of Children of Mentally Ill Parents - An Overview. In: Wiegand-Grefe S, Mattejat F, Lenz A (eds) children with mentally ill parents. Vandenhoeck & Ruprecht, Göttingen, 145 - 170
4. Laucht M, Esser G, Schmidt M (1992) Mentally Abusive Parents - Risks for Child Development in Infancy and Small Childhood? Zeitschr Familienforsch 4: 22-48
5. Wan MW, Green J (2009) The impact of maternal psychopathology on child-mother attachment. Arch Womens Ment Health 12: 123-134
6. Deneke C, Lucas T (2008) Outpatient and day inpatient treatment of mentally ill parents with babies and toddlers. In: Lenz A, Jungbauer J (Hrsg) children and partners of mentally ill people. dgvt-Verlag, Tübingen, 39-62
7. Field T (1995) Infants of depressed mothers. Infant Behavior and Development 18: 1-13
8. Reck C (2012) Depression and Anxiety Disorder in the Postpartum Period. In: Cierpka M (Ed) Early Childhood 0 - 3. Springer, Berlin Heidelberg, 301 - 310
9. Papoušek M (2001) Postpartum depression and its impact on child development. In: Braun-Scharm H (Ed) Depression and comorbid disorders in children and adolescents. Scientific publishing house, Stuttgart

(formerly: Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf)

Conflict of Interest: The author has no conflict of interest in connection with this article.

Published in: Kinderärztliche Praxis, 2015; 86 (6) pages 348-355