Insight into mental illness and child maltreatment risk among mothers with major psychiatric disorders

OBJECTIVES: This study examined the relationship between insight into mental illness and current child maltreatment risk among mothers who had a major psychiatric disorder and who had lost custody of a child because of abuse, neglect, or having placed the child at risk of harm. Specifically, a measure of insight was examined in relation to systematically observed parenting behaviors known to be correlated with past child maltreatment and in relation to a comprehensive clinical determination of risk. METHODS: Forty-four mothers who had a major psychiatric disorder were independently rated for their insight into their illness, the quality of mother-child interaction, and the overall clinical risk of maltreatment. RESULTS: Better insight into mental illness was associated with more sensitive mothering behavior and with lower assessed clinical risk of maltreatment. The association remained when mothers with current psychotic symptoms were excluded from the analyses. Better insight did not appear to be associated with past psychotic symptoms, maternal psychiatric diagnosis, or the mother's level of education. CONCLUSIONS: Insight into mental illness may function as a protective factor that influences the risk of child maltreatment in mothers with mental illness. Measures of insight could be usefully incorporated into comprehensive parenting assessments for mothers with psychiatric disorders.     

Involvement in the child welfare system among mothers with serious mental illness

OBJECTIVE: This study sought to determine the association between maternal schizophrenia and major affective disorders (serious mental illness) and child custody arrangements in a sample of Medicaid-eligible mothers. METHODS: Medicaid eligibility and claims data were merged with data from the child welfare system in Philadelphia for 1995 to 2000. The sample comprised 4,827 female residents of Philadelphia between the ages of 15 and 45 as of 1996, who were initially eligible for Medicaid through Aid to Families With Dependent Children between 1995 and 1996 and who had at least one family member younger than 18 years at the beginning of the study period. Logistic regression was used to determine association between maternal mental illness and involvement in the child welfare system. RESULTS: Among the 4,827 mothers, 7.2 percent had a serious mental illness and 4.4 percent had other psychiatric diagnoses. More than 14 percent of mothers with serious mental illness received child welfare services, compared with 10.8 percent of those with other psychiatric diagnoses, and 4.2 percent of those without a diagnosis. After the analyses adjusted for a past inpatient episode, race or ethnicity, and age, mothers with serious mental illness were almost three times as likely to have had involvement in the child welfare system or to have children who had an out-of-home placement. CONCLUSIONS: The results suggest the urgent need for increased planning and coordination between the child welfare and mental health systems, including provision of parenting support as part of mental health treatment for mothers.     

Social Distance,Bargaining Power,and Compliance with Rules on a Hospital Ward†

Objective: This qualitative, case-based study drew on attachment and ethological theories to explore the role of mistrust, a severe attachment attitude, in the development and causation of abusive parenting behavior in mothers with severe, recurrent depression. Method: The study analyzed a priori codes from redacted comprehensive assessments of eight women with depression and child protective services involvement to explore how mistrust was expressed; its links to extreme defenses and reported childhood experiences; and its consequences for relationships and help seeking. Analyses also identified specific stimuli that elicited abusive parenting behaviors and explored the context of depression in relation to women’s attachment and caregiving histories and mental health care follow-through. Results: Linked to suppressed feelings of vulnerability, mistrust was expressed in suspicions about support and in feelings of abandonment and betrayal. It was associated with an absence of support, family violence, role reversal, and parental mental illness. Mistrust affected mothers’ ability to maintain supportive relationships and to get help for their depression, which was a persistent part of their lives. A child’s cries, lack of support, partner abuse, and threats of abandonment triggered abusive parenting behavior, likely by tapping into core attachment pains related to unacknowledged longings for support. Unprepared to deal with these feelings, mothers became frustrated and redirected or displaced their anger onto their children. Conclusions: Mistrust may play a role in the dynamics of abusive parenting in mothers with severe, recurrent depression. Early identification and preventive intervention efforts that address this attitude could be beneficial for parenting.     

The role of coping in maintaining the psychological well-being of mothers of adults with intellectual disability and mental illness

BACKGROUND: Mothers who have a child with intellectual disability (ID) or mental illness face a lifetime of caregiving responsibilities and challenges. The present study investigated changes over time in how mothers cope with the challenges of caring for an adult child with disabilities and the effects of changes in coping on maternal well-being. METHODS: A sample of 246 ageing mothers of adults with ID and 74 mothers of adults with mental illness was drawn from two parallel longitudinal studies of later-life caregiving. RESULTS: There was considerable variability at the individual level in the degree to which mothers changed over time in their use of problem-focused and emotion-focused coping strategies. For both groups, an increase in their use of emotion-focused coping led to declining levels of well-being. For the parents of adults with ID, an increase in their use of problem-focused coping resulted in a reduction in distress and an improvement in the quality of the relationship with their adult child. For the parents of adults with mental illness, an increase in the use of problem-focused coping had no effect on levels of distress, but led to an improved relationship with their adult child. CONCLUSIONS: The present study underscores the importance of coping in the lives of older mothers of adults with disabilities.     

Influences of maternal mental illness on psychological outcomes for adolescent children

The research literature associating maternal mental illness with problematic mental health outcomes of adolescent children typically controls for neither the effects of family stresses and lack of support, nor the effects of parenting style. To address this gap, we explore the effects of maternal psychiatric symptoms and community functioning on child outcomes in a diverse sample of seriously mentally ill women caring for their teenaged children. In hierarchical multiple regression, for youth depression, we find effects for parenting style and maternal mental health; for youth anxiety and efficacy, effects involve the interplay between maternal symptoms and community functioning.     

A small-scale randomized controlled trial of the revised new forest parenting programme for preschoolers with attention deficit hyperactivity disorder

The revised new forest parenting programme (NFPP) is an 8-week psychological intervention designed to treat ADHD in preschool children by targeting, amongst other things, both underlying impairments in self-regulation and the quality of mother–child interactions. Forty-one children were randomized to either the revised NFPP or treatment as usual conditions. Outcomes were ADHD and ODD symptoms measured using questionnaires and direct observation, mothers’ mental health and the quality of mother–child interactions. Effects of the revised NFPP on ADHD symptoms were large (effect size >1) and significant and effects persisted for 9 weeks post-intervention. Effects on ODD symptoms were less marked. There were no improvements in maternal mental health or parenting behavior during mother–child interaction although there was a drop in mothers’ negative and an increase in their positive comments during a 5-min speech sample. The small-scale trial, although limited in power and generalizability, provides support for the efficacy of the revised NFPP. The findings need to be replicated in a larger more diverse sample.     

The influence of maternal stress and distress on disruptive behavior problems in boys

OBJECTIVE: The current study examined how self-reported maternal stress and distress are associated with child disruptive behaviors. METHOD: Mother and teacher ratings of child disruptive behavior problems (attention problems, aggression, and delinquency) were collected for 215 male participants, ranging in age from 9 to 12 years. Participating mothers also provided self-report data on socioeconomic status (SES), parenting stress, and distress (depression and anxiety/somatization). RESULTS: Low SES was significantly associated with both mother- and teacher-reported child disruptive behavior problems. Regression analyses indicated a relation between parenting stress and mother-reported child disruptive behavior problems, even when controlling for SES. Results also indicated a significant relation between maternal distress and mother-reported child disruptive behavior problems (particularly attention problems), even when controlling for SES and parenting stress. Maternal stress and distress were not significantly related to teacher-reported child disruptive behavior problems. CONCLUSIONS: Although the lack of an association between teacher-reported behavior problems and maternal stress and distress could be interpreted as a rater bias by these mothers, it may be that the mothers' symptoms are associated with a stressful home environment, thus exacerbating child disruptive behavior problems and eventually leading to a reciprocal relation between symptomatology in mothers and children.     

Predictors of treatment response in depressed mothers receiving in-home cognitive-behavioral therapy and concurrent home visiting

Home visiting is a child abuse prevention strategy that seeks to optimize child development by providing mothers with support, training, and parenting information. Research has consistently found high rates of depression in mothers participating in home visiting programs and low levels of obtaining mental health treatment in the community. Successful treatment of depressed mothers in home visiting programs holds the potential to improve maternal and child outcomes. In-Home Cognitive-Behavioral Therapy (IH-CBT) is an adapted treatment for depressed mothers, which is provided alongside home visiting and seeks to optimize engagement and impact through delivery in the home setting; a focus on issues important to young, low-income mothers; and a strong collaborative relationship between therapists and home visitors. This study examined predictors of depression status at posttreatment in 60 mothers who received IH-CBT and concurrent home visiting. Variables considered included demographics, illness history, severity, and numbers of treatment sessions and home visits. Results indicated that young maternal age, fewer episodes of major depressive disorder, lower depression severity at pretreatment, lower levels of symptoms of personality disorders, and more treatment sessions and home visits predicted asymptomatic status at posttreatment.     

Timing of mental illness onset and motherhood

The timing of mental illness onset in relationship to birth of children was explored as a possible indicator of the extent to which mothers experienced difficulties in parenting and functioning. Analyses employed data from a longitudinal study of urban-based, primarily minority mothers with mental illness (N = 379) who had parenting responsibility for their minor children. We found that women who were parents first and experienced mental illness onset after the birth of all their children showed the most positive trajectories over the study course. Mothers whose mental illness onset occurred before the birth of any of their children also showed improvements in functioning and symptomatology over time. In contrast, mothers whose mental illness onset had occurred in temporal proximity to the birth of a child showed little improvement. They also were younger, on average, at first birth, and had the largest number of children. Thus, timing of mental illness onset and childbirth may be predictive of longer-term maternal functioning and therefore may be useful in clinical assessment and treatment.     

Time Demands of Caring for Children with Autism: What are the Implications for Maternal Mental Health?

This study examined the relationship between maternal mental health problems and both caregiving time and experience of time pressure for 216 mothers of children with autism. Data describing caregiving time was obtained using 24-h time-diaries. Standard questionnaires were used to assess time pressure, social support, children’s emotional and behavioural problems, and maternal mental health problems. After adjusting for the effect of children’s age, maternal social support, and children’s behaviour problems, time pressure but not hours of caregiving, had a significant positive relationship with maternal mental health problems. Findings suggest that the quality of home-based care for children with autism may be adversely affected if time pressure experienced by caregivers compromises their mental health and well being.     

The role of coping strategies in predicting change in parenting efficacy and depressive symptoms among mothers of adolescents with developmental disabilities

Background Parents of children with developmental disabilities (DD) face greater caregiving demands than parents of children without DD. There is considerable variability in parents' adjustment to raising a child with DD, however. In line with a strengths‐based approach, this study explores coping strategies as potential mechanisms of resilience among mothers of adolescents with DD. This study examines the frequency with which mothers use various coping strategies and the extent to which those strategies moderate the relationship between adolescent behaviour problems and aspects of maternal well‐being. Both positive and negative dimensions of well‐being are explored, with maternal depressive symptoms and perceived parenting efficacy examined as outcomes cross‐sectionally and longitudinally. Methods The present study focuses on 92 mothers and their adolescents with DD. The adolescents had a wide range of diagnoses, all with continuing special needs. Data were collected from mothers through interviews and self‐administered questionnaires when their adolescents were aged 15 and aged 18. A structured assessment of the adolescent was completed during home visits at age 15. Results Mothers reported frequently using strategies of denial and planning but rarely using strategies of mental and behavioural disengagement to cope with recent stressful situations. Adolescent behaviour problems were found to contribute to greater symptoms of depression and lower feelings of parenting efficacy as well as increases in depressive symptoms over time. Mothers of sons, but not daughters, reported increases in parenting efficacy across their child's adolescent period. Above and beyond adolescent factors, several coping strategies emerged as significant predictors of mothers' symptoms of depression and perceived parenting efficacy. Moreover, use of Active Coping/Planning, Positive Reinterpretation/Growth, and Behavioural/Mental Disengagement as coping strategies moderated the impact of adolescent behaviour problems on maternal depressive symptoms. Conclusions This study extends previous findings by focusing on both positive and negative dimensions of parent well‐being during their child's adolescent period. Adolescence can be a stressful time for parents, with typical developmental tasks entailing additional strains for parents of adolescents with DD. The present findings point to several coping strategies that may reduce the impact of challenging behaviours during this period on mothers' symptoms of depression and feelings of parenting efficacy. Certain coping strategies were found to exert a greater impact on maternal well‐being for parents of adolescents with higher levels of behaviour problems, suggesting that interventions may benefit from an increased focus on this group of mothers with heightened caregiving demands.     

Association of maternal dopamine transporter genotype with negative parenting: evidence for gene x environment interaction with child disruptive behavior

Although maternal parenting is central to child development, little is known about the interplay between molecular genetic and environmental factors that influence parenting. We tested the association of the 40-bp variable number tandem repeat polymorphism of the dopamine transporter (DAT1; SLC6A3) gene with three dimensions of observed maternal parenting behavior (positive parenting, negative parenting and total maternal commands). A significant nonadditive association was found between maternal DAT1 genotype and both negative parenting and total commands during a structured mother-child interaction task, even after controlling demographic factors, maternal psychopathology and disruptive child behavior during the task. Furthermore, the association between maternal DAT1 genotype and negative parenting was significantly stronger among mothers whose children were highly disruptive during the mother-child interaction task, suggesting a gene-environment interaction.     

Social skills and behavior problems of urban, African American preschoolers: role of parenting practices, family conflict, and maternal depression

This study examined the role of parenting, family routines, family conflict, and maternal depression in predicting the social skills and behavior problems of low-income African American preschoolers. A sample of 184 African American mothers of Head Start children completed participant and child measures in a structured interview. Results of regression analyses revealed that mothers who utilized more positive parenting practices and engaged in more family routines had children who displayed higher levels of total prosocial skills. Positive parenting and lower levels of maternal depressive symptoms were predictive of fewer externalizing and internalizing child behavior problems. Lower family conflict was linked with fewer externalizing problems. Implications of the study for future research and intervention are discussed.     

Association of maternal and child blood lead and hemoglobin levels with maternal perceptions of parenting their young children

Biological and psychosocial factors affect child development and behavior. Whereas biological underpinnings behind the neurotoxic effects of lead are studied extensively, the effects of psychosocial factors contributing to poor behavioral outcomes in lead-exposed children are not well understood. Parental attributes and practices may moderate or mediate the effects of lead on children's behavioral outcomes. We investigated the hypothesis that maternal and child lead and hemoglobin levels are associated with maternal perceptions of their parenting. Specifically, we hypothesized that children with higher blood lead (BLL) and lower hemoglobin concentrations would be associated with poorer maternal self-assessments of their parenting skills or the mother-child relationship. Children aged 13-55 months and their mothers (n=109) were recruited from among the participants of a previous lead and anemia screening study and from preschools in Montevideo, Uruguay. The mother-child pair attended two study visits: one to collect biological samples and answer demographic and child questionnaires, including statements regarding parenting; and a second to evaluate maternal IQ, depression and stress, and child development. Of the children, 51.6% had blood lead concentrations (BLLs) ≥ 5 μg/dL, 18.0% had anemia, and 8% had both conditions. Among mothers, 48.4% had BLLs ≥ 5 μg/dL, 16.0% had anemia, and 11% had both. BLLs ≥ 5 μg/dL in mother or child were associated with lower maternal perceptions of being skilled at discipline (p<0.05). Maternal anemia was associated with lower likelihood that mothers would let their children explore and play (p<0.05), whereas child anemia was associated with maternal perception of lower emotional support (p<0.01). In addition to shared environmental exposures, parenting and family interactions need to be considered as potentially contributing factors to poorer outcomes in lead-exposed children.     

Predicting and understanding developmental delay of children of adolescent mothers: a multidimensional approach

Divergent literatures on potential relationships among psychological, biological, and contextual factors that may contribute to mental retardation and other types of developmental delay in the children of adolescent mothers were reviewed. A linear model was proposed to describe the direct and indirect effects of learning ability, maternal health, social support, personal adjustment, cognitive readiness for parenting, and infant characteristics on adolescent parenting and child development. Because the validity of the model can be determined through the use of causal modeling (LISREL), it holds the potential for determining a unique set of risk factors that may produce developmental delay in children of adolescent mothers. These factors can serve as the targets in designing intervention programs for such mothers.     

Maternal parenting styles and mother–child relationship among adolescents with and without persistent attention-deficit/hyperactivity disorder

We investigated mothering and mother–child interactions in adolescents with and without persistent attention-deficit/hyperactivity disorder (ADHD) in a sample of 190 adolescents with persistent DSM-IV ADHD, 147 without persistent ADHD, and 223 without ADHD. Both participants and their mothers received psychiatric interviews for diagnosis of ADHD and other mental disorders; and reported on the Parental Bonding Instrument about mother's parenting style, the Social Adjustment Inventory for Children and Adolescents for interactions with mothers and home behavioral problems. The mothers also reported on their ADHD and neurotic/depressive symptoms. Our results based on both informants showed that both ADHD groups obtained less affection/care and more overprotection and control from the mothers, and perceived less family support than those without ADHD. Child's inattention and comorbidity, and maternal depression were significantly correlated with decreased maternal affection/care and increased maternal controls; child's hyperactivity–impulsivity and maternal neurotic trait were significantly correlated with maternal overprotection; and child's inattention and comorbidity, and maternal neurotic/depressive symptoms were significantly correlated with impaired mother–child interactions and less family support. Our findings suggested that, regardless of persistence, childhood ADHD diagnosis, particularly inattention symptoms and comorbidity, combining with maternal neurotic/depressive symptoms was associated with impaired maternal process.     

Children of Mothers Diagnosed with Serious Mental Illness: Patterns and Predictors of Service Use

Children who have a parent diagnosed with a mental illness are at risk of psychiatric and behavioral problems; yet, these children do not necessarily receive needed services. Research has investigated correlates of child mental health service use, but not for these high-risk children. This study is part of an NIMH-funded, longitudinal investigation and describes child problems, service use, and predictors of service use for 506 children of 252 mothers diagnosed with serious mental illness. Mothers are primarily poor, minority women from urban areas. A multilevel-model approach is used to examine service use for multiple siblings in a family. More than one third of children had received services (from school or mental health agencies) in their lifetimes. Service use was predicted by child demographic characteristics (being male, non–African American, and older), social context variables (more negative life events, less financial satisfaction, and more parenting dissatisfaction), and maternal psychiatric variables (positively by high levels of case management receipt and affective diagnoses, negatively by maternal substance abuse history). In a subsample of target children, mothers' rating of child behavior problems additionally predicted service use. Implications of results for research and intervention are discussed.     

The Longitudinal Link Between Parenting and Child Aggression: The Moderating Effect of Attachment Security

This study examined whether infant attachment security moderates the association between parenting in preschool and later aggressive behavior among a sample of children at high risk for developing conduct problems. Participants were 82 adolescent mother–child dyads recruited from the community. Infant attachment status at age 1 year was measured using the Strange Situation. When children were aged 4.5 years, mothers reported on their self-efficacy in regards to parenting, and mothers’ positive parenting and criticism were coded from direct observations of parent–child interactions. In grade 1, mothers reported on their children’s aggressive behavior. Infant secure attachment significantly moderated the association between observed maternal criticism and child aggression. That is, among insecurely attached children, higher levels of maternal criticism were associated with more severe aggression. This longitudinal finding suggests that a secure attachment may buffer the deleterious effects of harsh parenting on child aggression.     

Early indicators of developmental risk: Rochester Longitudinal Study

Early indicators of schizophrenic outcomes were sought in a group of children of chronically ill schizophrenic women. A sample of pregnant women with varying degrees of mental illness were examined during the perinatal period and recruited into a 4-year longitudinal evaluation, which included cognitive, psychomotor, social, and emotional assessments at birth, 4, 12, 30, and 48 months of age. The mothers varied on mental health dimensions of diagnosis, severity of symptomatology, and chronicity of illness. Other factors included in the analyses were socioeconomic status (SES), race, sex of child, and family size. Hypotheses were tested to determine the relative impact of three sets of variables on the child's behavior: (1) specific maternal psychiatric diagnosis, (2) severity and chronicity of disturbance independent of diagnosis, and (3) general social status. We found that a specific maternal diagnosis of schizophrenia had the least impact. Neurotic-depressive mothers produced worse development in their children than schizophrenic or personality-disordered mothers. Both social status and severity/chronicity of illness showed a greater impact on development. Children of more severely or chronically ill mothers and lower-SES black children performed most poorly. These results do not support etiological models based on simple biological or environmental transmission of schizophrenia. The role of social and family environmental factors in predicting child cognitive and social-emotional competence was further evaluated using a multiple risk index. Children with high multiple environmental risk scores had much worse outcomes than children with low multiple risk scores.