Introduction

It can be challenging to talk to children about a sensitive topic such as their parent’s mental health difficulties. Nonetheless, it is essential that children be informed about their parent’s mental illness and given the opportunity to express how their parent’s health issues might be affecting them. This chapter will explore some of the issues related to having conversations with rather than to young people and, similarly, to “opening up” a discussion rather than “imposing” information. In this chapter, the term “children” refers to the offspring of those with a mental difficulty, illness, or disorder, and includes adolescents as well as younger children.

It is our belief that supporting parents to hold conversations about their mental illness with their children, in an age-appropriate and sensitive manner, can empower parents by acknowledging their critical role within the family setting (Marston et al., 2014). In this way, parents are reinstated as the experts in their children’s lives, often at times when they are feeling disempowered by the course of the illness and treatments. Acquiring and applying these skills is not necessarily easy, however. Within this context, it might be helpful to consider what it is like for parents to discuss with their children other sensitive or personal topics such as sex, divorce, death, or a physical illness and the skills that parents might need to do this, and issues or problems parents and children might encounter during and after such discussions. Thus, the skills used to discuss parental mental illness could well be generalized into other family conversations.

A parent’s mental illness is often the “elephant in the room” or the shameful secret that everyone knows is there but no one talks about. Mental illness is likely to affect the parent’s behavior, which the child might notice but not always understand. Within these families’ systems, children need to be provided with a framework for understanding what is happening in their family and given permission to talk and ask questions. Moreover, strategies are required to counterbalance the pervasive negative stereotypes and stigma often associated with mental illness within and outside the family.

Why children need to understand their parent’s mental illness

Young people who lack information about their parent’s mental illness may interpret their parents’ behavior in the context of their own limited and often inaccurate understanding, which in many ways is often far worse than what is actually the case, leading children to experience distress or confusion (Garley et al., 1997). Similarly, without an accurate understanding of their parent’s illness, young people might blame themselves for their parent’s behavior or depressed state.

In comparison, having the opportunity to discuss and talk about a parent’s mental illness addresses children’s fears for themselves, the unwell parent, and the family (Cooklin, 2013). Focht and Beardslee (1996, p. 9) found that enhancing children’s understanding helps them to develop a sense of coherence regarding what they are seeing, experiencing, and feeling, and this “helps them to trust their own experience.” Resilience is associated with understanding; for example, young people, whose parent had a mental illness and who were identified as resilient, recognized that things change over time, both in themselves and in their parents’ illness. They were also able to distinguish between themselves and their parents’ illness and see themselves as independent of it (Beardslee and Podorefsky, 1988). These young people understood that they were not the cause of their parents’ illness. Beardslee and Podorefsky (1988, p. 67) summarize these findings: “[O]ver time they [the resilient young people] had come to accept the fact that they could not cure their parents, although they could in certain important ways contribute to their well-being.” Likewise, Cooklin (2013) argues that explanatory discussions can help young persons achieve some distance from their parents’ emotional life and assist young people in developing their own thinking.

Holding conversations with children about what is happening for their parent also gives them the language and confidence to ask questions and initiate further conversations themselves. Importantly, it gives young people the permission to seek help and support if and when they require it. If young persons assume a carer role, talking to them allows them to be openly involved in the treatment, care, and support of their parent and family, and be consulted as “experts” as to what might need to happen and when. Being open and honest about parental mental illness decreases the potential for children and parents to feel stigmatized, as it suggests that there is nothing to be embarrassed or ashamed about. Discussing parental mental illness with young people gives them a voice in their families as well as more broadly in the community.

Giving young people the opportunity to discuss what is happening for them also allows others to respond specifically to any concerns young people might have. These discussions provide an opportunity for the parent to hear from their children what they are experiencing and any concerns that they may have; parents are then in a position to better support their children and address or answer any questions that they might have. Finally, the main reason to hold these conversations is that children have repeatedly said that they want to be informed about their parent’s mental illness (Garly et al., 1997; Grove et al., 2015; Reupert et al., 2012b).

Issues in discussing parental mental illness to children

Unless they have their own mental health or behavior issues, or are at risk of abuse or neglect, children may not be routinely identified by mental health or community services. Even if they are acknowledged, they are not routinely offered information or conversations about their parents’ illness (Maybery and Reupert, 2009). Thus, in the very first instance, there is often a lack of opportunity to talk to children, because they are not recognized as having their own needs or acknowledged as assuming caring responsibilities.

Children themselves might resist or be reluctant to discuss problems about their family because of the stigma associated with mental illness and the associated embarrassment and shame. They may feel that they are betraying their parents or experience conflicting loyalties in talking to others about what is happening at home, especially if coming from a single-parent family (Cooklin, 2006). Moreover, children may have been instructed by either one of their parents not to talk about “family issues” for fear of protective services or the shame associated with having others know about their parent’s illness.

While it is our strong belief that parents are best placed to hold these conversations with their children, some parents may not want to talk about their illness with their children because they believe that they are too young to know or that children will find the information distressing (Ueno and Kamiberru, 2012). Even though some parents might consider it important for children to know about their illness, some do not believe they have the skills to do this, or are too unwell and do not have the opportunity to talk to their children (e.g., because they are hospitalized) (Ueno and Kamiberru, 2012). Some parents may feel overwhelmed by the idea of trying to explain their illness, especially if they do not understand it themselves. Moreover, not all parents find the process of disclosure a positive experience; while some parents describe their relationship as improving after disclosure, others describe their children becoming “colder” towards them (Ueno and Kamiberru, 2012, p. 398). Some parents are concerned that their child would talk to other children about their illness and that this would become a source of gossip at school and in the community (Reupert and Maybery, 2007). Such research emphasizes the need to provide some basic guidelines to parents for discussing parental mental illness.

Sometimes, as outlined in Chapters 16 and 17, some parents may not identify as having a mental illness or be so preoccupied with their illness that they do not recognize the possible adverse impact of their illness on the family. We should hold in mind the fear that parents can have about disclosing their mental illness. We must be very careful as clinicians that parents’ reluctance is not emanating from our own stigma about mental illness (e.g., believing that they do not have the skills to hold conversations with children) or from a lack of confidence or skill in being able to empower and support the parent. It may be important to ascertain whether the parent identifies as having a mental illness and undertake a comprehensive assessment of the family circumstances (see Chapter 7). The role of others, including grandparents, other family members, and supportive adults and peers may be called on, along with directing children to psychosocial information from online or hard-copy resources. Nonetheless, attempts need to be made to engage with and include the parent where possible.

At times, mental health professionals or support workers may be asked to talk to children about what is happening to their parent. However, studies have demonstrated that many professionals do not have the time or resources to work with children, may not have the mandate to work with a client’s children (especially if working in the adult sector), or do not have the skills to work with children in an age-appropriate way (Maybery and Reupert, 2009). Knowledge in this area is often discipline specific; for example, social workers may know about family systems but know little about mental illness (Maybery et al., 2014). They may also not have the organizational support to include children in their work, either directly or indirectly, which is known to be essential to facilitate family inclusive practice (Reupert and Maybery, 2008), in press).

When should children be told about parental mental illness?

Children from a very young age will try to make sense of their parents’ behaviors, so any communication that is reassuring about their own and their parent’s safety is critical. There is no specific age when children should be told, but it is important to acknowledge that even young infants will become aware of the tone and mood of a parent’s voice and facial expressions. Toddlers can be told about their parent’s mental illness as they start to link words with emotions and may understand that their parent “has a sad sickness.” Books or stories may be particularly useful as a medium to discuss what is happening in families for younger children. For example, The Blue Polar Bear, by Samantha Tidy (available online), targets children aged 5–7 whose parent has a dual diagnosis (mental illness and substance misuse).

Children may often make remarks about their parent, especially when changes occur in the health or treatment of a parent, and such occasions may provide an opportunity to explore issues further. Opportunities to have these kinds of conversations can be taken up by anyone who has a positive relationship with a child and is trusted by the parent and family. Questions asked by children might suggest that they already know something about the illness, and this again provides a useful opportunity for the adult to prompt them to articulate any concerns or queries that they might have. It is important to take cues from the children and keep checking on what they understand and what they want to know more about. Information and language provided to young people should always be age appropriate and be seen as part of a longer journey of learning about mental illness and health, feelings, and relationships. In this way, conversations about parental mental illness should be ongoing as children will have different questions and concerns at different ages.