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Parenting issues in mothers with schizophrenia

Article  in  Current Women s Health Reviews · February 2010

DOI: 10.2174/157340410790979734

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Parenting

Current Women’s Health Reviews, 2010, 6, 51-57

Bentham Science Publishers Ltd.
Parenting Issues in Mothers with Schizophrenia
Mary V. Seeman  

Author's Copy

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Abstract

Background: Schizophrenia has been seen as a severe and persistent illness

that disqualifies mothers from adequately parenting their children.

Aim: To understand the scope of the issue, to learn about the subjective
experiences of mothers and children, to appreciate the impact of psychotic
illness on children at various ages, and to review the necessary components of
intervention programs.

Results: Approximately half of all women with a diagnosis of schizophrenia

are mothers. The rate of custody loss in this group is high. Most women with
schizophrenia value their roles as mothers, and their adult children remain
attached to them. There can be serious harms, however, associated with being
the child of a mother with psychotic illness. Most of these appear to be
mediated not by the illness itself but by associated risks: poverty, substance
abuse, domestic violence, social isolation, and/or substandard housing.
Intervention programs have begun to cut across agency divisions to provide
wraparound care in multiple domains for families in distress.

Conclusion: Schizophrenia in mothers poses problems for offspring but does

not preclude effective parenting.

Keywords: Schizophrenia; Mothers; Children; Parenting; Carers

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Introduction:
The general impression in the medical community is that schizophrenia
always takes the form of a mental illness so severe and persistent that it all but
precludes “good enough” parenting. [1, 2] Because of the pessimism, mothers
with schizophrenia are given relatively little opportunity to establish their
parenting competence. Child welfare agencies, whose mandate is the safety
and well-being of children, are quick to intervene and remove a child from the
home of a mother with a psychotic illness. This is understandable since
children’s rights must take precedence over those of adults, children being
vulnerable and defenseless in the face of potential neglect or harm. Mothers
however, can be vulnerable as well, especially when they are ill, isolated, and
socially and economically disadvantaged, as happens frequently in association
with schizophrenia.

The nature of this illness is such that patients may not be aware they are ill.
This, too, is a vulnerability since symptoms are attributed to factors other than
illness and medical help is shunned.

Even those women who are in active treatment may stop taking antipsychotic
drugs once they become mothers because they equate “taking pills” with being
perceived as ill and, therefore, open to losing custody of their child. [3] They
stop treatment, hoping to impress child agencies by the fact that they are no
longer “on pills.” Agency staff, from their perspective, see this as “non-
compliance.” Another reason for stopping treatment is the sedation induced by
antipsychotic medications. Mothers, especially new mothers, want to stay
vigilant and so they discontinue sedating medications in order to be more
attentive to their infants’ cries, a paradox since, as a result of being good

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mothers, they are subsequently tagged as “non-compliant.”

Bonding between mother and child is as a two-way process that depends on

contributions from both members of the dyad.    Based on indications that
women with schizophrenia did not bond well with their infants, [1, 2]
clinicians frequently advised women with schizophrenia to not become
parents. [4] They found women suffering from psychosis to be “remote,
insensitive, intrusive and self-absorbed” [2] and the quality of mother-infant
interaction to be poor when compared to other mother-infant pairs. Even at
one year postpartum, when few residual symptoms of postpartum exacerbation
of illness remained, interactional disturbances were noted. [5] This led to
concerns about the child’s future development and, most importantly, about
the child’s safety.  

Also studied has been the risk of inherited psychiatric illness. This last
concern loomed large in the mid 20th century, with many countries in the
Western world and in Asia passing sterilization laws targeted at the mentally
ill. This was an attempt to stop inheritance of “the schizophrenia gene.” In the
1930s and 40s, between 200,00 and 400,000 mentally ill and mentally
disabled persons were sterilized in Germany, but also 65,000 Americans, 3000
Canadians and more in Scandinavian countries [6,7] and in Switzerland. The
numbers in Japan, China, and Korea are harder to ascertain. Sterilization of
less than perfect individuals was considered progressive during the first half of
the century, a scientific way of “purifying the race.”

Although stigma related to schizophrenia and other psychotic illnesses

continues, it has taken different forms. Today’s concerns are not about

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inheritance; they are mainly about safety and about the adequacy of mothers to
ensure optimal emotional and cognitive development of children.

Are these concerns warranted? What is the evidence about women with
schizophrenia, parenting ability and child outcome?

Scope of the Issue

In the days when psychiatric patients were locked in asylums, there was little
chance for pregnancy. Nowadays, though individuals with schizophrenia in
most parts of the world still have fewer offspring than the general population,
the gap is quickly closing. The fertility ratio for those with schizophrenia (in
comparison to the general population) in a Swedish birth cohort for the years
1915-1929 was 0.42. [8] A two cohort (1918-1927 and 1932-1941) study, also
from Sweden, found the ratio to be 0.30 for men and 0.50 for women. [9] A
more recent birth cohort study (1950 to 1959) from Finland reported a ratio of
0.44 for men and 0.83 for women. [10] Though fertility for men with
schizophrenia remains relatively low, women with this diagnosis today are
parents almost as often as are other women. Approximately 30% of patients
with a first episode psychosis are already parents prior to their first admission
and, presumably, prior to receiving any treatment. [11] Treatment with the
older antipsychotics reduced fertility but this is no longer the case; [12]
women treated with newer drugs now have nearly as many children as women
who are free from this illness. Approximately half of all women with
schizophrenia are mothers. [13]

Despite the fact that they bear children as often as anyone else, mothers with

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schizophrenia may not end up being their children’s primary care providers.
[14] Some give their children up for adoption, though less so now than in the
past. Nowadays in North America, Children’s Aid agencies often apprehend
children when the mother is ill and (sometimes) return them when she is
better. Mothers may not always know how to get their children back. [15] All
parents with a diagnosis of serious mental illness are vulnerable to losing
custody of their children, most studies reporting rates of custody loss of about
60%. [16] In a study of nearly 5000 Medicaid-eligible women in Philadelphia,
mothers with serious mental illness (schizophrenia and major affective
disorder) were found to be almost three times as likely as other mothers to be
involved in the child welfare system or to have children placed outside the
home. [17] The reason for the high rate of child apprehension may be because
women with psychotic illnesses are inadequate mothers, but it may also be
because they are treated with unwarranted suspicion by child welfare agencies.
[18]

When mothers do retain legal custody, the children may, in reality, be brought
up by grandmothers, fathers, or other relatives and be consequently at risk for
inconsistent rearing by a succession of intermittent caregivers. Custody
awarded to grandparents is becoming increasingly commonplace in this
population [19]. This may work well, but may also be problematic because of
the grandparents’ age, health, and economic situation. Rates of disturbance for
children in kinship care are reported as being high, but not as high as for
children in foster care. [20-22] Children in foster care, and this bears
emphasis, are at higher risk of mental health problems than children reared by
their mentally ill mother. [23]

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Concerns about Parenting Skills

The concerns raised about parenting in the context of schizophrenia are, first
and foremost, safety. Will the mother be able to ensure the physical care and
safety of her child? Will her symptoms or medication side effects – delusions
about neighbors, for instance, or apathy, or cognitive distortion, or sedation –
prevent her from being diligent in her care?

The best known concept of parental adequacy is Winnicott’s “good enough

mothering.” [24] This term refers to a mother who provides a “holding”
environment, always present when needed but receding into the background
when not needed. The main requirement is responsivity to the child’s needs
(this is sometimes called attunement). Responsiveness means parenting that is
prompt, contingent on the child’s behavior, and appropriate to the child’s
needs and developmental stage. Responsiveness means time spent with the
child in child-focused activities, open communication, a low level of criticism,
a high level of warmth and praise, consistency, and ability to set reasonable
limits.  

For small children, adequacy of parenting is generally judged by the absence

of abuse and neglect. As the child grows older, other domains of parenting
grow in importance. Foreman [25] divides these into: the ability to solve
instrumental and emotional problems, the ability to resolve conflicts, the
ability to be emotionally responsive and involved, the ability to set limits, the
ability to induct the child into his or her social role. Assessing competent
parenting requires skill and experience. It includes a multidisciplinary
assessment of the mother, paying special attention to her understanding of her

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illness and its optimal treatment, her strengths and challenges with regard to
parenting, and stages of child development as they apply to her child. An
important part of the assessment is direct observation of mother and child
interaction and an inquiry into the availability of social supports. [26]

While it is relatively easy to ascertain the presence of gross neglect or abuse,

the other qualities of parenting that are judged important by parenting experts
are more difficult to evaluate. Parent competency instruments are imperfect
and subject to cultural bias. Playing with the child, as an example, or
providing toys for the child, is not part of the tradition of parenting in all
families. The most crucial risk, assessing potential violence against children,
is difficult to predict, no matter what the screening questions or the
observational context. [27-31]

Subjective Experience of Mothers

The subjective experience of mothers is captured in qualitative studies that

allow mothers to voice their feelings and concerns about their double identity:
victim of illness and mother. Many women report that having children
decreases their illness symptoms, increases their pride and motivation, and
brings them closer to their extended families. These are, of course, self-reports
and, it has been suggested [32] that “impression management” (in an attempt
to protect against custody loss) can color these reports. The perception among
these mothers is that they are at the mercy not only of their care providers but
also of malicious neighbors and family members and that reports of raised
voices, empty refrigerators, or noncompliance with treatment can quickly lead
to loss of their children. [3] Nonetheless, all qualitative analyses of mothers’
narratives speak to the goal of being the best possible mother [33]. They also

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speak to the many obstacles that stand in the way of the goal: stigma of mental
illness, poverty, lack of support, lack of resources, role strain, cognitive
problems, ill health, side effects of medication, shame and guilt at decisions
impulsively taken. [34, 35]

Chernomas et al. [36] report that many women suffering from psychotic
illness face contradictory choices. They feel their isolation but do not initiate
friendships for fear of rejection. They crave intimate relationships but are
frightened into immobility lest they be taken advantage of, as that has been
their experience. They worry about taking antipsychotic drugs, especially
during pregnancy, but are afraid of what might happen if they stop. They
rejoice in motherhood (the love they feel, the sense of renewed purpose, the
positive identity of being a mother rather than “a schizophrenic,” the new
support they attract) but are often overcome by stress, exhaustion, fear of not
having enough money, fear of loss of custody, and also a vague angst that
their children are too much like them and may end up, like them, developing
schizophrenia. Several women interviewed for the Chermonas et al. study, had
lost their children to foster care or adoption and spoke of their deep and
unending grief and anger. The particular conditions of the mother-child
separation (degrees of choice, control, and the opportunity for ongoing
communication) can be crucial in determining the extent of psychological
harm to the mother. [37]  

Dipple et al. [38] describe the experience of 58 mothers who were patients of
the psychiatric rehabilitation services in Leicester, U.K., 68 % of whom were
permanently separated from at least one of their children and subsequently lost
almost all contact. These authors, too, point to the prevalence of grieving and

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loss in this group of women. In a larger sample of mothers with serious mental
illness (N=379), Oyserman et al. [39] emphasize the joy their participants
experienced at being able to parent, although there was also the
acknowledgement of added burden. The burden was that of all mothers: new
tasks and schedules; child disobedience or misbehavior; difficulty of child’s
eating and sleeping routines; the need for respite; illness (their own or their
child’s). But the burden weighed more heavily because of lack of financial and
economic resources and because of the requirements of mother’s psychiatric
illness (appointments, medication taking, need for stress-free quiet time,
interpersonal discomfort).

Themes that emerged in many of the interviews were problems blamed on

physicians (for changing diagnoses and treatments), problems blamed on
society (because of stigma and custody issues), on economics (the strain of
single parenthood), on spouse and family of origin (for lack of support), and
on themselves (for inadequacy in disciplining their children). [35] Despite the
problems, these women see themselves overall as good mothers. They
describe themselves as emotionally available, sensitive to their children’s
needs, and accepting of their children’s idiosyncrasies.

Mothers with schizophrenia invariably describe their children as central to

their lives despite the difficulties of coping with mental illness and
motherhood at the same time. They worry about their children being adversely
affected by their illness. They also struggle with juggling responsibilities to
their children with the requirements of attending to their own mental health.
They are concerned with the stigma of being a mental health consumer and
they worry that their children will be included under the stigmatizing
umbrella. [40]

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Risk Factors for Children

Children of parents suffering from schizophrenia are sometimes born with

inherited vulnerabilities and many, in addition, are exposed to early
disadvantage. The interaction of experience and genetic predisposition during
early life affects the chemistry and circuitry of the brain indelibly, setting the
stage for developmental problems. [41]

Children of mothers with a diagnosis of schizophrenia face a host of

challenges because, besides suffering from a serious illness, the mothers
usually are also struggling with poverty and isolation. Lack of adequate
prenatal care, poor maternal diet during pregnancy, maternal use of alcohol,
tobacco, and caffeine all accumulate to undermine a child’s resilience.

In addition, a large number of women with schizophrenia have partnered with

men who have psychiatric problems of their own, thus increasing the
hereditary disadvantage for the children. [42] Because of the instability of
many of these partnerships, the children, more often than not, have only one
consistent parent.

Because of all these factors, there are significantly increased risks for preterm
delivery, low birth weight, and small-for-gestational-age among the offspring
of women with schizophrenia. The rate of still birth and infant death is twice
as high in this population as in the general public. [43-47] Some studies find
mortality risks for children of schizophrenia mothers to be elevated from birth
through early adulthood. [48]

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Infants of Mothers with Schizophrenia

Because of the many factors just described, the infants of women with
schizophrenia are described as poorly developed relative to comparison infants
[2, 49-51] Attachment difficulties have been postulated. Attachment refers to a
protective bond between an individual and a caregiver. It means that closeness
to the caregiving person is instinctively sought whenever danger looms. When
separated from the mothering person, securely attached young children show
only slight distress, which tends to readily respond to comfort or distraction.
Those with insecure attachment may appear indifferent to the mother’s leaving
or to her reappearance or, in contrast, may desperately cling to their mothers at
the point of separation and, at reunion, may again cry and cling (this is called
anxious attachment). Infants of psychotic mothers and of depressed mothers
have been shown to demonstrate more insecure attachment than infants of
manic mothers during the first year of life. [5] At 1 year of age, children of
mothers with schizophrenia have been found to display anxious attachment
more often than comparison children. [52] The personality attributes of
mothers, as well as their child-rearing behaviors appear to be the main drivers
of toddlers' insecure attachment. [53]

Older Children of Mothers with Schizophrenia

When compared to other children, young offspring of women with

schizophrenia show increased rates of delay in walking, visual dysfunction,
language skill disorders, enuresis, and disturbed behavior (especially poor
social competence). [54] They also show high levels of neurological
abnormalities relative to offspring of mothers with affective psychosis. [55]
Findings vary, however. In a matched study of 37 children (aged 8-16) one of

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whose parents was diagnosed with schizophrenia, Somers [56] found that the
majority were indistinguishable from children of well parents in terms of
physical health, positive family feelings, friendships, hobbies and household
tasks. The at-risk children did, however, suffer more often from psychiatric
disturbance, have more problems associated with school, less contact with
relatives and more at-home time. It is important not to attribute the problems
that these children face to poor parenting. The children are, by definition,
genetically at-risk for developmental problems and, furthermore, may be
negatively affected not only by social circumstances, but also by prenatal
exposures, and mental health and substance use problems in the father. Factors
associated with mother’s illness, such as her absences due to hospital
admission, [57] the inconsistencies in parenting that may then result, and the
extra responsibilities that children of ill mothers often assume, [58] may also
contribute to the problems they experience. Most studies concur that the
diagnosis of schizophrenia in the mother has less impact on her parenting
style than do the many associated factors.

Adult Children of Psychotic Mothers

Dunn [59] obtained information via semi-structured interview from nine

adults with a psychotic parent who answered a newspaper advertisement. Five
themes emerged from this qualitative analysis: a) abuse and neglect b)
isolation c) guilt and loyalty d) grievances with mental health services e)
supports. These interviewees reported being abused by their mothers and
abandoned by their fathers. They spoke of isolation from peers, extended
families, and communities. They reported being uninformed about the nature
of their mothers’ illness. They described not wanting friends to visit because

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of their mothers’ bizarre behavior. They expressed responsibility, suspecting

that their birth had somehow precipitated illness in their mothers. Those who
had been placed in foster care or in the custody of their fathers, felt guilt for
having abandoned their mothers. All but one study participant described
negative contacts with mental health services. Many felt their mothers were
mistreated in hospitals and they felt guilty that they had facilitated hospital
admissions. They felt that mental health professionals never took the trouble
to understand their situations. Most remained loyal to their mothers and
wanted to look after them. Although they all described painful connections
with their mothers, five of the nine also recalled a special loving relationship
with her.

Duncan and Browning [60] studied current attachment issues in 23 adults who
were raised by parents with schizophrenia. These interviewees describe a
range of difficulties in forming secure adult attachments, particularly in the
areas of trust and intimacy.

It is clear that adult children who speak out about their experiences of growing
up with a mother with schizophrenia have many unhappy stories to tell. What
is not clear is how representative these stories are nor how these complaints
compare with the retrospective accounts of children growing up under
analogous conditions of poverty, single parenthood, and ill health.

Risk of Mental Illness

The children of parents with schizophrenia have a greater risk of mental

illness in adulthood than comparison groups of children. Long term follow up
studies of offspring of mothers with schizophrenia from New York, Sweden,
Denmark, Israel, and Japan calculate the estimated risk of schizophrenia in
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these children to be 7-16%. [61-64] In addition, they show that the offspring
are vulnerable to a variety of other mental health problems. [65] In the
Copenhagen study, 25 children were reared by their mothers and 25 were
reared apart from their mothers. Counterintuitively for some, more
psychopathology was found in those reared away from their mothers. The
explanation may lie in the fact that more severely ill mothers were more likely
to have lost custody; nevertheless, this finding underscores the fact that
rearing by a mother with schizophrenia is not necessarily the main risk factor
for psychopathology. [66] Severing the relationship between child and
primary caregiver places the child in jeopardy. Remaining in the home of an
ill mother is also a hazard, but can be countered by effective intervention.

Interventions

Some studies find that the mere fact of reducing maternal symptoms helps
mother-child relations, [67] but a recent review emphasizes that this is not
enough. [68]

Parenting intervention for mothers with schizophrenia include didactic

parenting classes, direct parenting coaching of mothers, parent support groups
in which parents help one another, and time-limited co-parenting support.
These services can be delivered in residential programs, therapeutic nursery
programs, or community-based programs. [26] Mother and baby inpatient
units (MBUs), where mother-child contact can be maintained during acute
episodes of illness and where clinical staff can assess and assist mothers with
parenting skills, have been popular in the United Kingdom and in Australia,
but a recent survey of MBUs found that the provision of services was highly

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variable. [69] It is, therefore, not surprising that there is no hard evidence for
their effectiveness. [70] In-home interventions are presently being evaluated.
[71]

Both provider and parent groups endorse family-centered, strengths-based,

emotionally supportive, and comprehensive approaches that include essential
services such as family case management, 24-hour crisis services, liaison
where needed, and advocacy. [72-75] Importantly, effective services need to
bridge the adult/child mental health divide and provide family-centered care.
Interagency cooperation is recognized as essential, although difficult to
implement. [76-79]

The term, “wraparound,” is increasingly being used to describe a family-

driven, strengths-based planning approach that provides individualized care
and uses an array of both formal services and natural supports. [80] Another
phrase often used is “system of care.” A system of care is a network of
structures and relationships that is held together by shared values and that
operates across administrative and funding jurisdictions. [81, 82]

A family-driven system of care is based on the needs of children, parents, and

extended family. It is strength-based and supports choice, ongoing evaluation,
and accountability. It promotes partnerships between families and
professionals, involves collaboration between multiple agencies and service
sectors, provides individualized services in a variety of domains, and is
culturally sensitive. The cultural sensitivity of a service refers to the ability of
its staff to understand, value, and incorporate the perspective of the family into
service provision and, whenever possible, provide services in the family’s
language of choice.

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In a wraparound system, there is a single point of entry for the many services
that are provided. Among these are attention to mother and child health, [83]
substance abuse counseling, case management, liaison with schools, the legal
system, welfare, crisis management, housing, transportation, vocational help,
spiritual, cultural, and recreational guidance, and respite care. Ideally, the
service are open ended and sensitive to the stigma associated with mental
illness, unfortunately a fact of life for parents with mental illness and their
children.

Cook and Steigman [84] emphasize the paramount importance of custody

concerns in families where severe mental illness has been diagnosed. They
advocate a focus on prevention of custody loss through advanced directives
(where the children are to go in case of illness exacerbation), respite care, and
supports specifically designed to preserve the custodial relationship. They
would like child rearing to be recognized for the role it plays in mother’s
recovery rather than to be seen as a barrier to that recovery. Cook and
Steigman identify assessment of parenting strengths and needs, birth control
counseling, pregnancy decision-making support, trauma and abuse counseling,
peer support, parent mentoring, self-help, support groups for children, and
medication management as important aspects of a system of care for families
where a parent suffers from severe mental illness. Counseling around benefits
and entitlements is also critical for low income mothers, many of whom may
be intermittently homeless and require housing support. [85] In addition,
clients on limited incomes need help with financial planning, dealing with
Welfare-to-Work expectations [84] and preparation for employment.

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Conclusions

Schizophrenia is a serious illness that weighs heavily on women who are

trying to be good mothers. It also poses biological and psychological problems
for their children. Many interventions are available to mitigate the risks to the
family, but more research is needed to understand what works best for whom
and how such services are best delivered. With support for mother and for
children, schizophrenia does not preclude effective parenting.

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