Key points are not available for this paper at this time.
The United Nations (UN) Convention on the Rights of the Child 1 affirmed that the child, for the full and harmonious development of his/her personality, should grow up in a family environment, in an atmosphere of happiness, love and understanding. Nations must take appropriate measures to protect the child from all forms of physical or mental violence, maltreatment or exploitation, while in the care of parents or other persons entrusted with their care. This Convention was adopted by the UN General Assembly in November 1989, and has been ratified by 192 nations. It is not only because of this authoritative pronouncement, but also because the ambition of medicine is to prevent disease, that the issue of the mental health of children of mentally ill parents is important: a promising preventive strategy is to work with high risk groups, such as these vulnerable children. Most of these children are born and reared in low-income nations, which have a dearth of resources and also, in some cases, of essential knowledge. There is a paradoxical relationship between wealth and birth rates: nations in Europe, North America and elsewhere, with advanced health systems and strong scientific contributions, have fewer than 10 million births/year. We are concerned not only to improve practice in these nations, but also and especially to find solutions for those countries in which the other 125 million infants are born. Thus, we seek to recommend state-of-the-art services to those that can afford them, and creative interventions to less prosperous nations. The needs of children, which parenting must address, can be listed as follows: • Basic care (shelter, nutrition, hygiene, clothing and medical care). • Safety (protection from dangers, including unsafe people). • Emotional warmth, so that the child feels unconditionally valued and secure. This will involve comforting, praise, and considerate, affectionate and loving care. • Encouragement of learning. This requires quick and contingent responses to the child's language and questions, play, support to schooling, and the promotion of social opportunities. It is aided by understanding the child's world, his/her temperament, strengths and weaknesses, and may require special skills, for example in handling disabilities. • Guidance and setting consistent boundaries for culturally acceptable behaviour, aiming to equip the child with consideration for others, discipline and internal moral values. This is achieved by supervision and monitoring (protecting the child from poor role models), coaching, and rewarding good behaviour. Unacceptable actions are discouraged in a consistent way, providing a model for anger control and conflict resolution. • A stable family base for engagement with the wider world. Although there is much variation, these needs progress in phases from birth to adolescence, starting with attachment to primary caregivers in the first year. From the security thus provided, the child achieves gradually increasing autonomy, and starts to develop a sense of self, to recognize and regulate emotional states, and to discover the limits of personal power and identity. During the preschool years, an important task is peer-group integration. Towards the end of the first decade, the child begins to establish personal preferences, to take responsibility and develop a sense of right and wrong. Adolescence is marked by psychosexual development and a gradual move towards adulthood. The term “parenting” covers the adult activities that meet these needs, and foster the child's development into a successful adult. “Caregiving” is sometimes preferred, in order to include adoptive and foster parents, and others, such as grandparents, who have a substantial role in caring for the child. Parenting may be disturbed by many factors other than mental illness, including poverty, adverse events and family violence or disruption. The neighbourhood may be violent and deprived, or, in contrast, may have strong cooperative networks. There are cultural and religious influences such as attitudes towards family privacy and cooperation, social responsibility, authority and ethnicity. Violence, war and persecution on a national scale provide the most unfavourable circumstances for caregiving. Most patients with chronic psychoses, and many with recurrent mental illness, are prescribed prophylactic or therapeutic drugs, and many women become pregnant when taking them. Although it is generally advisable to avoid medication in pregnancy, the risks of stopping it often outweigh the risks to the foetus. Pregnancy does not usually become detectable before 30–40 days gestation, so that infants conceived by women on regular drug intake are exposed to teratogenic hazards. In the case of most psychotropic drugs, this risk is controversial and slight. But valproate (possibly also carbamazepine) can cause neural tube defects and learning disability; this risk is reduced, but not eliminated by folic acid. Electroconvulsive treatment can precipitate early labour, preventable by a tocolytic drug. Neonatal toxicity and/or addiction have been reported in some babies exposed to lithium, anti-psychotics, antidepressants and benzodiazepines. The risks to the breast-fed infant have been exaggerated 2. We focus on ethanol, narcotics and cocaine, which are the best researched. Exposed infants face many adverse factors: their parents often have mental disorders (such as depression and paranoid disorders); they often abuse other drugs; they suffer from multiple social problems and poverty; many do not seek antenatal care. The infants may be affected by maternal malnutrition and infections such as hepatitis, HIV or venereal diseases. The quality of care, as much as drug effects, is a strong predictor of outcome. All three drugs are associated with an increased risk of short gestation and low birth weight. In addition, some exposed infants are small for gestational age, which carries the implication of placental insufficiency, not just early arrest of intra-uterine life. This in itself, without drug exposure, can result in neurological dysfunction, and possibly language delays and emotional disorders 3. Selecting some salient points, ethanol, taken in excessive quantities, may be teratogenic, causing a general increase of congenital abnormalities. There may be microcephaly and permanent brain damage; foetal alcohol syndrome is a leading cause of mental retardation. A notable complication of narcotic addiction is the withdrawal syndrome, against which methadone maintenance does not protect. A specific complication of cocaine abuse is placental abruption. The long-term effects of both opiates and cocaine have been much studied, but without reaching a consensus on cognitive deficits or behavioural problems, when controlled for social deprivation 4. There are claims that subclinical anxiety, depression or stress during pregnancy can have lasting effects on the child. They include pregnancy complications, prematurity, low birth weight or intra-uterine growth retardation, foetal or neonatal distress, and developmental delay, but there is no consensus on these effects. Perhaps the best supported claim is that mid-trimester anxiety affects mental health in mid-childhood, but such investigations are plagued by many confounding factors. Only rigorously designed cohort studies can substantiate these claims. Domestic violence during pregnancy carries the risk of foetal injury and death. It can also severely affect maternal attitudes and morale. Many pregnancies are unplanned, but most of these are merely mistimed, and are fully accepted. A minority remain persistently unwanted. The number of these unwelcome pregnancies is much reduced in nations that allow termination of pregnancy; even so some are carried to term. Unwanted pregnancy is a significant problem in many low-income countries 5. It is associated with an increased risk for denial of pregnancy, foetal abuse, neonaticide, depression, mother-infant relationship disorders and emotional disorders in children. Cohort studies of unwanted pregnancy and its psychological outcomes are a research priority. The complex functions of parenting may be disrupted, to a greater or less extent, by all forms of parental mental disorders. It is not so much the diagnosis that confers the risk, but the severity and chronicity of psychopathology. It is important to emphasize that investigations of parenting report statistical associations in large samples. There is much variation in psychopathology (its severity and duration), and in each patient's personality, coping and social circumstances. Many parents with severe depressive, anxiety or eating disorders, and even those suffering from psychosis, make excellent caregivers. Different disorders have their effect through common pathways: • Parental preoccupation. Any preoccupation, whether in the form of worrying, obsessional or angry ruminations or delusions, can impair vigilance and the readiness to respond to the child; so this effect will be seen in anxiety, obsessional and querulant disorders, as well as psychoses and emotionally unstable personality disorders. Inattention is also caused by involvement in time-consuming morbid activities, such as compulsive rituals, bingeing or drug abuse. It will result from disorders affecting the faculty of attention itself, such as depression. If this withdrawal of attention is frequent and prolonged, setting will be and the will be without the to • Emotional This in severity from of the child to a or of to withdrawal seen in severe depression or • This is in depression, psychosis, and withdrawal from drugs or can find an in the children, who are than or other anger is a of severe mother-infant relationship disorders. may be on the child in disorders. is a problem for some with personality disorders. • behaviour. A child may be exposed to or on emotional responses may the This is sometimes The from to treatment in some countries that children Parenting is also affected by other factors: • has a general with social which may to its or may result from illness, or social with chronic have a number of pregnancies and to other often have to with violence, and They are vulnerable to and and face such as or diseases. have unwanted are and in have with mental disorders. The children may have a risk, and are to have behavioural associated taken or the of maternal increase the risk of mental disorders in the children. • The relationship may be severely by parental with these parents with their children for short or and this may affect The child may be by his/her parents taken or in The child will often have to be to or foster care, so that multiple there is foster care support from the parenting will be In addition, mentally ill women the of their children. Many do in to other foster care or and this is a of of or with mental health and social may to seek or to that they are parents, because of this • of the parental illness, the child may be exposed to and The parents also suffer from which may to social that the of the child's In parents with chronic psychosis, is often and with a low quality of and involvement In parents with recurrent and the parental relationship is often the are frequent and is the mental especially in women of There is much its on and many studies have its effects on mother-infant and child of and may also affect maternal a adverse effects are not some are by the with their children The effects of depression on parenting include the • parents and They and and are often They may less and influences have most in when is and • the parents can There may be a in the quality and of is with and morbid and • associated relationship may be associated with language delays through their other There may also be effects on physical health and development There are from and on an of maternal depression with low infant weight and The growth of the mother-infant relationship is the psychological in the It is this gradually during the first the which to make and the of their There is a of this even before the In the may be as an in foetal abuse the a of for the is common in the early in a small progress to and the infant of the for loving severely and to emotional abuse. The when way, to abuse and children are high risk of disorders may affect and excessive of and sometimes with a of and may children of to and the world. can to anxiety, and social If an severely the can suffer from and The attitudes of some or to and to chronic and growth Parenting by women with learning is as they are from to the They are often and have many other children may be increased risk of abuse and but there is a dearth of on parenting by these of persons with severe mental disorders are increased risk of psychological not only because of parenting problems, but also because they may a and be exposed to a of factors associated with parental mental include complications, deprivation and of social conflict and family life. They are vulnerable to There is the effect of child behaviour, parental the other factors may be such as the of the child or the of a or family The child's mental health and social is best by multiple less by and by It is that in and marked by discipline and especially maltreatment are important factors in poor behavioural and emotional A focus on parenting excellent for early forms of infant can be to They include the of in severe abuse. children have behavioural to the of only in of and excessive early is the in infants of The infant an important in the relationship with his/her to a through and is by the of these the end of the first attachment disorders may be attachment may an to form and by which in other forms of social attachment may be to and attachment of and early is a seen in the first years, marked by in and other There is a with associated with In there may be and that parenting is in are but children exposed to drug abuse or suffering maltreatment may be increased disorders, and in the first decade, into adult and Although there are many factors much research has an of these disorders with parenting The most is and an atmosphere of and to a of and The child's is from the It of a of risk factors leading to social problems in social and disorders and abuse, as well as There may be also depression and A syndrome of depression can be in There is much of increased depression, and in the of mentally ill Parental depression has many for children, which include problems in and But these may be to risk (such as and in or maternal depression There is on the of parental anxiety on the development of morbid anxiety in children. The of anxiety is and through and In the years, abuse in vulnerable so in the children of factors may the but studies have that parenting is also through of supervision and low of conflict and learning by Child physical abuse may be especially associated with but also with and depression Child is as the to meet a child's needs and in of health or development It may severe depression, and abuse is a with including a to prevent suffering or seek medical or mental health care, of of the child with unsafe or denial of or social opportunities. It is important to it from the of children in with many social problems may be the best This to to should not be to without such as severe and from and the syndrome of that can also be in Emotional maltreatment is a of severe disorders of the that are emotionally and to the child's for and and or to children that they are and or the child, such as by or to violence can be this Emotional maltreatment may be a risk for than other forms of abuse This term covers caregivers who or in their children The include or of and of by such as or their This is usually into of the and of an In neonaticide, there is usually no mental illness, but an emotional marked by or but forms of can during and can be in is but of It is often associated with mental illness, especially depression, but also the child, severe mother-infant relationship disorders and psychosis, or may that this of mental will increase but we that the strategy is to recognize the risk and take to for the and the when their should include the of important factors. is of mental to We that care of a child the of should be The UN Convention on the Rights of the Child 1 that nations should provide preventive health care and for practice in adult short of this The or even the of children is often not must be that many patients are parents, and that their children are increased risk of psychological must the to include and family life. must be in for mental health We as a a by are as a or have the care can provide for of In those with there should be a parenting as in This some but the for family support and During must be for by the children, from with other The may in the to the children. This should include parents child development and the of parenting in with social should be for long-term parenting support in the This include for parents and for children. should be to a of the children. The UN Convention attention to the for family this is in the best of the this should be a of for parenting and are for The in the of parenting by an a with severe mental between mental health and and other is If and resources a should be as as to and The for is that the between the diagnosis of pregnancy may be and birth may be can be The should include the general medical a from the of the mental health and the It is to include the patient's of the and a of the wider There are many to be antenatal care, early of a the of the and the care of the It is essential that the mental health is as as the into will support in child and the child may to be to a for pregnant and women may be can also be when a or with mental is starting a The UN Convention that nations should appropriate and health care. as a of child or a of adult have in a and also in and They can a handling severe and illness, and resources may include with other services and and The of the is a providing care for the mentally ill and child a the cultural and the resources There is a for research into the of these The and of mother-infant is of the by these In all who with it is essential to this in that or that of problems will to the involvement of child often to should be in for of or it take for to to If there is of the child, these are with of is the an to the to is strong to the health and of the is treatment often achieves a All of should that and drugs, can have during and should women who are pregnancy, or are to they should be to abuse in In an issue is the of foetal alcohol effects. In narcotic the of the is the drugs of abuse should gradually be withdrawal from or an such as can precipitate a foetal by of methadone or is the best with less intra-uterine growth and require case abuse can be by in or The infants should be in for to or withdrawal can effects, and improve and behaviour. There are a and treatment services their and should be The UN Convention that child should include to support the child and his/her as well as to and prevent child In all actions children, whether by or the best of the child should be than family is the primary and the child's parental even when his/her parental mental Nations must responsibility, and setting the for and including health to the and the in the they are Child requires the of many social • The The Convention the role of the as the for the growth and of children. The involvement is of and are often the of support in some the only • child are the in nations. • In with these or as an and religious can support maltreatment and social and networks. • are the of children who be reared by their They include and forms of care. The early and of maltreatment has been it is associated with severe mental this a of We take as an In this case the severe psychopathology the child's right to into conflict with the right to and medical The may involve the medical the general an and the from child care. the diagnosis is the with the parents is the should make it that has been the to the child, and that is to and the child. the only is to children. is of the most events a can and even so this from a mental It may also be for the child. also have the and of children in and was often of sometimes leading to disruption. research has been on the of through and in high risk in so as some severe mental disorders especially the social associated with are risk this is the of these We resources for child in the nations that most of the children. We the of a of by of from We this by to and national child social services and other to child We from nations in and three in and the in the and and three in and America and as well as many nations. A of • 1 of prosperous nations, with and but for example which has to research on child • of nations and which may have but are towards an for has child • of countries and with children, but of to establish • of nations, of which is an the problem of child maltreatment is an of A Child is is the strong of family We also their improve child in their We only have for a of their and have the for and The first was of this the of patients and even The was especially of primary care and who often mental health The was to recognize these children as a high risk and take Child and mental health services are essential for the promotion of mental health in vulnerable children. They provide treatment for all the disorders They have a role in and with other research and and In is with a focus on the on the child and on the social and family of the child's life. Many specific forms of and psychological have been including family and infant and cognitive appropriate to the and of child In the of it that these services in many low-income nations. In the an of child and mental health on responses from The does not of nations, but it is that most countries with high birth have child and million children are born each has in and only child with and mental retardation. In nations, care is by often with no in mental the United of America is short of child of the research is to best practice interventions for mentally ill parents and their children, which are and culturally acceptable in low-income nations. This include the role of in vulnerable children and their The is and It should with the of a but for They can take a in and They can up and can be not only towards but also towards who have with children for example and and other in the who can be to children in the needs of children of persons with severe mental requires to in the practice of adult support for the and with child a of services for child and mental
Brockington et al. (Wed,) studied this question.