Intervention strategiesprevention and treatment

Despite this plethora of information concerning the influence of parental psychological and physical illness on children, relatively little has been written about clinical intervention or prevention and even less research is available. However, there are a number of implications for prevention and treatment.

When parents with serious physical or psychological illness are seen as outpatients, especially if they are subsequently admitted to hospital, it should be routine to enquire about children—their ages, developmental and scholastic progress, child care arrangements, and family support. Furthermore, over time clinicians should ask about children's understanding and knowledge of the parental illness and the extent to which it has been discussed. These issues will need to be carefully and sensitively handled. Families have a range of ways in which they communicate and it is important not to compound the parents' problems by making them feel their illness is harming their children. As far as inpatients are concerned, it is important that facilities should be available for children visiting and, unless specifically contraindicated, regular contact should be encouraged, and appropriate play and other materials should be available. Discussions should be held with the patient and/or relatives about child-care arrangements, and the patient and family need to be helped to think about providing the child with an appropriate explanation about parental health and absence.

Communication either about the parental illness or the associated discord may help to alleviate some of the risks for childhood problems. ^.i3 Studies of marital disruption and divorce have found that children cope better with marital conflict when they are given some explanation or told that the conflict has been resolved. (84,85) Children often feel left out and without knowledge of the parental illness; they may be particularly likely to attribute any family conflict or disruption to themselves in their effort to understand the changes taking place.

Less work has been conducted in families where the parent is physically ill, although reports of treatment once the family members are experiencing problems are providing some ways forward/86 Parents may consciously avoid disclosure because of the questions they anticipate from their children, particularly about death. Communication in this context is not only a matter of disclosure of the illness but a starting point for ongoing discussion and questions, without which children may be at increased risk. (75)

The most important role of support services may be to rehearse with parents the kinds of questions that might occur and how they could respond, a strategy which may also facilitate discussion of the ill parent's anxieties. The clinical team need to think carefully about management of this issue since intervention can have significant positive effects if well handled. Some guidelines are available ^I,88 and preventive work has demonstrated the effectiveness of explanation and communication for children's ongoing development. A series of intervention studies with children of parents with major depression has shown marked improvement in family functioning and child outcome.(89) These interventions took place over six to ten sessions, some with parents and children individually with at least one family meeting. The core elements were cognitive teaching about affective disorders, risks, and resiliency factors in children, linking the cognitive teaching to the individual's life experience, using increased understanding to reduce children's feelings of guilt or blame, and support for the development of relationships both within and outside the family.

Some preventive intervention can clearly be accomplished earlier. In infancy it is possible to promote the development of secure parent-child attachment, which should be protective even if the parental illness is chronic. Maternal sensitivity can be enhanced using videotaped mother-child interactions, which can increase the rate of secure attachment in at-risk families.(90) A recent intervention study in postnatal depression found that a number of psychological treatments, including counselling, led to early remission of postnatal depression and helped the mothers to feel more positive about their children at 18 months postpartum.

In conclusion, children of parents with physical or psychiatric illness are at risk of a wide range of developmental and psychiatric difficulties. Future work should be directed to developing and evaluating ways of providing support so that parents can come to terms with their illness and its implications with the minimum negative impact on their children.

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