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Think Child, Think Parent, Think Family


Think Child, Think Parent, Think Family Impact of parental vulnerability on children Early and quickly is better Dr Adrian Falkov Senior Staff Specialist – PowerPoint PPT presentation

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Title: Think Child, Think Parent, Think Family

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

We Know
  • Multiple adversities vulnerabilities
    demonstrated current, lifelong generational
  • 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
  • MIPs of families known to childrens services
  • Comorbidity - MI, Substance Misuse PD

  • 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
  • Neglect has life threatening consequences

  • 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
  • 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

  • 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

  • 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

The Family Genes Recurrent, early onset Major
  • Onset depr in chhood a single MDD assoc with
    nearly 50 chance of recurrence in future (Kovacs
  • 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

Gene environment interplay
  • Caspi et al (03) longit study 5-HTTLPR
    (serotonin transporter gene-linked polymorphic
  • 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
  • It is the interplay between and cumulative effect
    of gene environment influences

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
  • Reduced stigma, shame, isolation
  • Harmonious relationships
  • Understanding parents illness
  • Families
  • Cohesion, harmony happiness as a result of
    accessible flexible equitable safe responsive

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

A Vision For Change?
  • Multiple, competing perspectives
  • Across profession, team, service, agency
  • Working better together everyones
  • Building AND Crossing Bridges
  • Shared understanding, role clarity common
    purpose Of course, but HOW?
  • Role of mental health-illness for staff in chs
  • 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

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

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

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

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?

Family mental health More support, better
  • 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,

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

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

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

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
  • Should an action that should be followed unless
    there are sound reasons for taking a different
    course of action

Resources caught between service science
  • 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

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
  • Paul Keating the power of the status quo -
    Occasional address UNSW, 15 April 2003

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

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

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

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
  • Capacity (skills, resources) to support
    intervene according to assessed need utilising
    evidence based interventions, early quickly
  • Evaluation research (tailored specific
    modifications of existing interventions

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

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

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

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

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?

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

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

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
  • 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

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

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

Working better together
  • Integration of research into practice
  • Making prevention / EI part of mainstream
  • 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

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

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.

Childrens understanding of parental psychiatric
disorder Improving outcomes for families
  • How can children understand what parents cant

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
  • 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.

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

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

  • 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

  • Improve identification, assessment and
  • 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

  • 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?

  • 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