Think Child, Think Parent, Think Family

1
Think Child, Think Parent, Think Family

• Impact of parental vulnerability on children
• Early and quickly is better
• Dr Adrian Falkov
• Senior Staff Specialist
• Sydney West CAMHS
• adrianfalkov_at_optusnet.com.au

2
We Know

• Multiple adversities vulnerabilities
  demonstrated current, lifelong generational
  impact
• Interplay genetic psychosocial adversity,
  vulnerability resilience Negative outcomes
  not inevitable
• Multiple (competing) needs (adult vs child MH vs
  Social care CP vs family support)
• Prevalence of MI parenthood across all service
  sectors tiers
• Parenthood amongst AMH SMS (pts who are
  parents)
• MIPs of families known to childrens services
• Comorbidity - MI, Substance Misuse PD

3

• Major public health opportunity - implics for
  better identification, intervention prevention
  
• Improving life chances lived experiences for
  parents children
• Family as NB target mechanism for change
• If parents do better so will children
• If children do better so will parents
• Investment opportunity early intervention,
  economic benefits of promoting enhancing
  resilience
• Neglect has life threatening consequences

4

• Stigma discrimination shame isolation
• Disruption to daily life chaotic lifestyle,
  lack of routines, parental hospitalisation
• Developmentally inappropriate roles
  responsibilities (young carers)
• poor parent-child interaction marked by parental
  disinterest, hostility, less involvement and poor
  communication
• Loss feelings of confusion, uncertainty, fear
  anxiousness, anger loyalty
• Poor understanding about the meaning of parental
  actions and concern about developing mental
  illness themselves
• Greater risks of emotional behavioural problems
• fear of being removed from the family

5
Also

• Tragedies (fatalities) highlight dangers of poor
  communicatn co-ordinatn between services
• Systems failures organisational malaise
  including insufficient AND poor use of resources
• Social capital, investment opportunities through
  improving life chances lived experiences for
  parents children
• Effective treatment rehab approaches
• Management leadership issues

6
And

• At some point in their lives, I believe, most
  human beings desire to have children and desire
  also that their children should grow up to be
  healthy, happy, self reliant.
• For those who succeed the rewards are great but
  for those who have children but fail to rear them
  to be healthy, happy self reliant the penalties
  in anxiety, frustration, friction perhaps shame
  or guilt, may be severe.
• Engaging in parenthood therefore is playing for
  high stakes.
• Furthermore, because successful parenting is a
  principle key to the mental health of the next
  generation, we need to know all we can both about
  its nature about the manifold social
  psychological conditions that influence its
  development for better or for worse
• John Bowlby Caring for Children
• A Secure Base Parent-Child Attachment Healthy
  Human Development

7
The Family Genes Recurrent, early onset Major
Depression

• Onset depr in chhood a single MDD assoc with
  nearly 50 chance of recurrence in future (Kovacs
  96)
• Chhood dysthymia 78 chance of subsequent MDD
  (Kovacs 96)
• A parent or sib with MDD has 2-3 fold greater
  risk for depr compared to gen popn risk (10)
• If the relative has severe, earlier onset
  (childhood / teens / 20s), recurrent MDD the risk
  becomes 4-5 X greater
• About 50 of predisposition / heritability
  accounted for by genes
• Multi locus patterns of inheritance
• Genetic vulnerability coupled to early adversity
  (abuse and neglect), life events and loss imposes
  even greater levels of risk

8
Gene environment interplay

• Caspi et al (03) longit study 5-HTTLPR
  (serotonin transporter gene-linked polymorphic
  region)
• Number of life events predicted subsequent
  depression according to number of short alleles
  at 5-HTTLPR position
• Sim interaction for effect on depression of no of
  chhood maltreatment indices between ages 3-11
• Neither depr scores nor MDD predicted by genotype
  alone
• It is the interplay between and cumulative effect
  of gene environment influences

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So What should it look like?

• Adults
• briefer, less frequent illness episodes
• Reduced hosp, relapse
• Improved cap to meet childrens neds
• Harmonious relationships, social connections
• Productive roles, educ employment
• Children
• Better self esteem, resilience
• Improved cognitive, emotional, behavioural fning
• Opportunities to achieve have fun ed
  attainment
• Reduced stigma, shame, isolation
• Harmonious relationships
• Understanding parents illness
• Families
• Cohesion, harmony happiness as a result of
  accessible flexible equitable safe responsive
  services

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Comprehensive service?

• Diagnostic
• Severity
• Population-based
• All family members
• Individuals v relationships
• MH Promotion, prevention

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A Vision For Change?

• Multiple, competing perspectives
• Across profession, team, service, agency
• Working better together everyones
  responsibility
• Building AND Crossing Bridges
• Shared understanding, role clarity common
  purpose Of course, but HOW?
• Role of mental health-illness for staff in chs
  services
• Prof awareness, knowledge, skills re MH of
  children their parents/carers
• Impact of vuln ch on parents
• Impact of vuln P on children
• Identify, assess, intervene, evaluate
• Family focussed, developmentally informed
• Strengths-based, protection oriented

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But Challenges and Dilemmas

• What does think child parent family mean?
• Dual diagnosis, Ingredients of complexity
• Thinking v Doing (Implementation)
• How will we know? (Evaluation)
• Information sharing v confidentiality
• Support v protection, Vulnerability v resilience
• Common experiences, competing needs
• Must v should
• Resources - Service v science imperatives

13
Invisible Children AMH Perspectives

• You know, the thing is, the kids are important
  but theres always so much going on, so much to
  do that you, well, you go in with good
  intentions but theyre so ill (pts), or chaotic
  or needy or doing worrying things that you, well,
  you kind of I guess just forget. I know I
  shouldnt but thats what happens

14
Childrens UnderstandingTom, Aged 7

• Its not like a tummy ache or a cold - but she's
  not feeling well. She thinks she's the king,
  then I know something's wrong - in the neck -
  where she speaks, (or maybe) the heart - it's a
  very important part of the body- makes you do
  things, or maybe the mind - not the brain because
  the brain is just to make you think the illness
  is the things she says

15
Young Carers - Liz Aged 11

• When I was younger, mum had a problem. She had
  difficulty with us 4 kids - sorting us out for
  school - she wasnt getting a lot of help and she
  was shouting a lot. Her words were all jumbled
  up - didnt come out properly. She was having
  too many cups of tea... Always asking me for cups
  of tea so i was late for school. I told the
  teachers an excuse that mum overslept and I had
  to make breakfast for the younger ones - mum
  didnt want them to know she was sick because she
  thought they were watching her and coming round
• Liz went on to state that she thought it very
  unlikely anyone was watching because if there
  were watchers Id have seen them - but I didnt
  tell mum this because she would have said how do
  you know its unlikely?

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Family mental health More support, better
connections

• Mental illnesses are often accompanied by the
  undefined burden that is borne by families of
  affected individuals and the community in terms
  of human and economic costs, as well as the
  hidden burden of stigma and human rights
  violations that may be encountered by this
  vulnerable section of the community
• Commonwealth Department of Health and Aged Care,
  2000

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What does Think Child Parent Family Mean?

• "When I use a word", Humpty Dumpty said, in a
  rather scornful tone, "it means what I choose it
  to mean, neither more nor less
• "The question is," said Alice, "whether you can
  make words mean so many different things"
  Lewis Carroll
• Definition normal vs abnormal / vulnerable
• Who? which individuals which families
• Social exclusion state intrusion vs neglect
• Stigma
• Happy families key ingredients??
• Parenting
• Enduring x gen vs prevention
• DV

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Dual diagnosis?

• Mental Illness Substance Abuse
• Mental Illness Domestic Violence
• MI in parent AND child
• MISA in BOTH parents
• Axis I AND II (psychosis PD)
• Depression/anxiety, alcohol abuse PD

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Ingredients of Complexity

• Quadruple diagnosis
• Diagnostic uncertainty
• Too much, too little, poor quality info
  difficulties across multiple domains
• 1 person, multiple difficulties
• 1 or more difficulties in gt 1 person,
  concurrently, at different times
• Early adversity, resilience susceptibility
• Staff education, training experience
• Multiple services agencies

20
Must v Should Policies, frameworks,
strategies and guidelines

• While there is no general legal impediment to
  using the directive (ie must) rather than the
  suggestive (ie should) in the Policy, 2 factors
  should be kept in mind
• Is it necessary to mandate (ie use the word
  must) that all employees in all circumstances
  behave in an exact manner and
• As a breach of the Policy may result in a breach
  of the code of conduct , the use of the
  directive should be limited to circumstances
  where an employees compliance with the Policy is
  not dependent on factors outside the employees
  control
• Should an action that should be followed unless
  there are sound reasons for taking a different
  course of action

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Resources caught between service science
imperatives

• Much increased awareness successes in carer
  consumer involvement, dev of materials for
  families professionals
• No clearly articulated, well evaluated models
  (Bendigo grp Fraser et al review of intervention
  programmes targeting ch wellbeing 26/520 papers
  only 7 methodologically strong). See SCIE review
• Need evidence to argue for resources
• Need resources to generate evidence

22
From Thinking to Doing Implementation

• Most things out there are designed to stop you
  making a difference. All the biggest bets in life
  are on the status quo. Plenty of people think
  they would like to change things but lack the
  energy or the imagination to clamber over, or
  beat a path through, the status quo only the few
  determined and inspired ones will make a real
  difference.
• Paul Keating the power of the status quo -
  Occasional address UNSW, 15 April 2003

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How Will We Know? Evaluation

• 'Here is Edward Bear, coming downstairs now bump,
  bump, bump, on the back of his head, behind
  Christopher Robin.
• It is, as far as he knows, the only way of coming
  downstairs, but sometimes he feels that there
  really is another way, if only he could stop
  bumping for a moment and think of it.
• And then he feels that perhaps there isn't'
• A. A. Milne, Winnie the Pooh

24
Competing needs

• Interplay between multiple psychosocial
  vulnerabilities socioeconomic disadvantage over
  the lifespan and across generations
• Dual diagnosis is the norm for State-funded,
  public sector services

25
Strategies, tactics and approaches

• SCIE Guidelines comprehensive approaches
• Conceptual frameworks learning materials
• Identification, assessment intervention
• Family intervention
• Parenting is a mental health issue
• Working better together
• Evaluation
• Political will, advocacy and tragedy (policies,
  resources and leadership)
• Stigma

26
SCIE Guidelines Comprehensive approaches

• Systematic service level identification
  recording of children, parents, families
• Appropriately tailored assm of need by relevant
  sectors of a competent, confident visible
  workforce
• Capacity (skills, resources) to support
  intervene according to assessed need utilising
  evidence based interventions, early quickly
• Evaluation research (tailored specific
  modifications of existing interventions
  approaches)

27
Conceptual Models

• Continuum of need
• Family Model Crossing Bridges
• Family Focussed Assessment

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Crossing Bridges Key Principles

• The MH wellbeing of children adults within
  families in which an adult carer is mentally ill,
  are intimately linked in at least 4 ways
• PMI can adversely affect the development and in
  some cases the safety of children
• Growing up with a MIP can have a negative
  influence on the quality of that persons
  adjustment in adulthood, including their
  transition to parenthood
• Children, particularly those with emotional,
  behavioural or chronic physical difficulties, can
  precipitate or exacerbate mental ill health in
  their parents/carers
• Adverse circumstances (pov, single p, social
  isoln, stigma) can negatively influence both
  child parental MH

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Crossing BridgesThe Family Model
4 Stressors vulnerabilities
1 Adult mental health
2 Child dev mental health
3 Parental fam relationships
4 Strengths, resilience resources
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IdentificationEvery Family in the Land?

• Epidemiological studies highlight widespread
  prevalence and complex interplay between MISA,
  childcare burden and social adversity
• Given the number of MISA adults of child bearing
  and rearing age there are substantial public
  health implics for better detection, intervention
  and prevention
• Surveys highlight relevance of considering
  childcare and protection issues amongst MISA
  services and dev of MISA perspective amongst all
  childrens services

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Assessment Key Areas

• Who to assess
• The child
• The ill parent
• Partners other key people in the childs life
• What to assess key domains
• Parenting
• MI /or SA in parent (MS risk harm to
  self/other diagnosis Rx Prognosis
  service/need match availability of resources
  broader social needs)
• Safety, wellbeing health of children
• How to assess
• Talking with children whose parents are MI or
  abusing substances
• Talking with parents / carers who are / may be MI

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FaMHliSTalking Together

• Child psychiatrist
• Do you worry you might upset your children if
  you talk to them about your difficulties?
• Adult psychiatrist
• Do you worry you might upset yourself?

33
Family intervention

• Early (age eg children)
• Quickly (stage of illness)
• Identify, assess, intervene, review
• Family as key target for early intervention
• ve impact on children reduces burden for parents
• ve impact on parents promotes children's
  wellbeing and safety

34
Heide Lloyd, Mother of Hannah Georgina

• I did not realise how depressed I was at the
  time now looking back I feel quite shocked to
  think that I coped with a new baby a toddler,
  having just given birth, believing that I could
  be living in a world where I thought I could hear
  even see people who were not there. This
  eventually subsided over about 5 months, though I
  had felt unable to share the experience with
  anyone, sensing disbelief feeling really afraid
  that I would be locked up my children taken
  away

35
Parenting is a Mental Health Issue

• Pivotal role in attachment, development
  positive mental health
• Mediator of good experiences, a buffer vs
  adversity NB determinant of successful
  transition to parenthood
• A potent source of adversity poor quality
  relationships
• Direct effects of abuse neglect
• Absence of sufficient protection against life
  events losses
• Early trauma later susceptibility to MISA
  poor adjustment
• Mechanism for transmission of adversity

36
Working Better Togetherprofessional perspectives

• I was scared. Thats the simple truth of it.
  Scared. Terrified. She (mother) was in the corner
  but he (father) was standing up. Shouting. I
  could see his veins pulsing. Like he was going to
  explode. He didnt want to come into hospital.
  Said his wife couldnt manage the children. He
  was usually so calm I was shocked at the change.
  It took a long time to get over that. Oh of
  course I did all the usual stuff trying to be
  calm, talking him down, pressing the security
  alarm. But I was still not prepared when it
  happened. Took me a long time to get over it

37
Working better together

• Thinking family when talking with individuals
• Supporting adults whilst ensuring the wellbeing
  safety of children
• Better identification and recording of vulnerable
  children, assessment of their needs and
  interventn according to assessed need
• Improving childrens parents understanding of
  and communication about MI ( SA)
• Identifying strengths

38
Working better together

• Integration of research into practice
• Making prevention / EI part of mainstream
  practice
• Availability of learning opportunities
• Workforce enhancements
• Local integration of teams and services
• Cross agency partnerships protocols
• Tackling stigma
• Resources best use of and credible argument for
  additional

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Evaluation

• Of what?
• Family Children MIP Partner
• Services frontline staff managers teams
  services agencies
• Intervention treatment, protection, support,
  prevention, protocols
• Implementation actions targets / benchmarks /
  standards
• Workforce knowledge attitude skill recruitment
  retention
• Involve family members - how will we know
  outcomes are improving
• Generate good arguments for resources and
  investment

40
Tackling Stigma Discrimination

• The subject first caught my attention twenty
  years ago when I came across a table of
  charitable giving showing cancer close to the top
  and mental health near the bottom. I wondered why
  care of the mind should rank so much lower than
  care of the body. The position is the same today.
  The cancer charities are followed closely by the
  animal charities. We give more to dogs than to
  those with mental problems.
• Jeremy Laurance
• How fear drives the mental health system.

41
Childrens understanding of parental psychiatric
disorder Improving outcomes for families

• How can children understand what parents cant
  explain?

42
Sam, Aged 10, about his Fathers Schizophrenia

• Schizophrenia problems are to do with your
  health, your head, stress and laziness and anger.
  Depression is when you feel lonely like nobody
  cares.
• When I was very young Dad was saying in 100 years
  the world will destroy itself. There will be
  mayhem and death and things like that. I think
  that I was about five. It made me very worried.

43
Childrens Understanding

• During a meeting with his family, Jumai, a 7 yr
  old described a conversation with his father
• We were talking about her and dad said about the
  controller - you know, for the TV. If you press
  all the buttons all the time very quickly and it
  jumps about all over - going crazy - thats like
  what was happening in Mums head. She was in
  hospital.

44
Crossing Bridges Prevention

• Reduce child exposure to parental symptoms
• Assertively treat parental illness
• Promote positive parenting
• Reduce exposure to parental discord
• Educate parents about MISA
• Educate children about MISA ways of coping
• Promote open discussion about MISA in families
• Facilitate support outside the home
• Promote opportunities for relationships
  achievements within school
• Address socio-economic factors

45
Conclusions

• Not possible to separate protection of children
  from wider support to families, especially when
  MI /or Substance misuse present
• Support for children families cannot be
  achieved by a single agency alone
• Children are vulnerable unsafe if staff in
  different agencies do not fulfill their separate
  distinctive responsibilities
• Combination of service structures that support
  staff together with awareness, knowledge skills
• Effective management leadership

46
Conclusions

• Improve identification, assessment and
  intervention
• A broader, inclusive approach MH social care,
  Child adult (parent), CP Family support
• A lifespan and cross-generational perspective
• Working together and crossing bridges
• Talking with children and parents (family
  approaches)

47
Conclusions

• Provide targeted training ongoing education
• Develop service level partnerships within
  between agencies
• Prevention early intervention - children's
  services as an explicit preventive component of
  adult services?

48
Conclusions

• Use Media opportunities
• Promote positive mental health tackle stigma
• Use evidence on prevalence of parenthood impact
  on children to
• make best use of existing resources
• argue coherently for additional investment
• improve clinical practice (assessment of need
  early intervention)
• Dev evidence base - models of good practice