Divorce

Physical Illness in Parents or Siblings

When a family member is chronically or seriously ill, parental resources in time, money, and emotional energy available to other family members are reduced. In addition, nearly all children have at some time wished that something bad would happen to a parent or sibling. If that person then falls ill, the child may literally believe that he or she caused the illness. This “magical thinking” is normal in young children and appears under stress even at later developmental stages.

To the extent that an ill child receives special treatment, sibling rivalry is exacerbated. This may be overt or concealed by the child’s guilt or parental shaming. A child or an adolescent often must take on extra chores to substitute for a parent or sibling. Parents can help by equalizing chores, discipline, positive parental attention, privileges, and treats as much as developmental stages and physical condition permit.

Childhood disability and illness have an impact on the whole family system. The sibling of a disabled child may be teased by peers. Providing accurate information about the disability can facilitate coping. Some siblings of children with severe, chronic disabilities are more likely to have symptoms of aggression, depression, social isolation, and oppositional behavior. Families who are already stressed (e.g., by financial strain or single parenthood) are at higher risk for emotional or behavioral symptoms.

Death of a Family Member

The death of a family member, particularly a parent or primary caregiver, is a traumatic event for a child that can elicit strong emotional or behavioral responses. One in 20 children experiences the death of a parent. Bereaved children often experience depressed mood, sadness, longing for the deceased, appetite changes, irritability, social withdrawal, declining school performance, and sleep disturbances, although children’s expressions of grief tend to be more intermittent than those of adults. In the first 2 months after parental death, the effect can be profound and may lead to the development of major depression and suicidal ideation. However, the severity of these symptoms generally wanes over time. In a longitudinal study of the psychosocial functioning of bereaved children from stable families, the children appeared similar in function to healthy control subjects (Fristad et al. 1993). If the death occurred under traumatic circumstances, the expected anger and grief may escalate to childhood traumatic grief or persistent complex bereavement disorder. If the death involves a child, the siblings must face their own grief in addition to their grieving parents’ emotional withdrawal. Suicide-bereaved children have to address grief as well as the stigma and anguish surrounding suicide. Suicide-bereaved children experienced more anxiety, anger, and shame than children bereaved from parental death not caused by suicide (Cerel et al. 1999).

The terminal phase of the parental illness may, in fact, be more stressful for the child than the death. During this time, the child is exposed to the physical changes and painful consequences of life-threatening disease. The child also becomes aware of the irreversible nature of the illness and the likelihood of death. Parental illness changes the structure and organization of the family. Family roles and routines change, and family cohesiveness may suffer as the ill parent becomes less available physically and emotionally, and the other parent may be exhausted by caretaking and grief. Terminal phases of illness require more resources for care, which may jeopardize the family’s financial stability. When a parent has been ill, the death may mark the end of a tragic and difficult period for the family and begin the process of healing and reorganization.

When a family member dies, the child should be allowed some choice in whether to attend the funeral (if developmentally appropriate). One study (Weller et al. 1988) showed that attendance at funeral activities did not result in increased psychiatric symptoms 2 months later. Extra support, such as an adult friend or relative, can be helpful through the funeral process, because the surviving parent may be too preoccupied with his or her own grief to be available to the child. Children can mourn, although they may express their grief in behavior rather than verbally. If the child is especially vulnerable because of a psychiatric disorder or additional stressors, clinical judgment should influence the decision about how to handle the funeral, and extra therapeutic support may be needed.

Parents should explain death in a matter-of-fact, concrete way. Religious explanations should be used only if these are consistent with family beliefs. The magical thinking and egocentricity that are characteristics of young children may lead them to believe that they are responsible for the death. They will often be too frightened or guilty to mention this and should be spontaneously reassured that they had nothing to do with the cause of the death.

The child’s conceptualization of death plays a role in adjustment. As children mature, they gradually develop an understanding that death is universal and irreversible. Children younger than 2 or 3 years do not understand at all; they are simply made anxious by the separation. At ages 4–5 years, death seems reversible, like sleep or a long journey. For 5- to 10-year-olds, death can be personified. A more realistic concept of death develops in children ages 10–11 years. Although by then most understand that death is universal, more than half of fourth graders do not yet clearly understand the irreversibility of death. Elementary school–age children tend to view death as a punishment for bad behavior. Although most adolescents cognitively understand the meaning of death, some behave as though they do not accept their own mortality.

The long-term effects of family bereavement depend on how well the surviving parents cope and are able to restore family life functioning. Open and honest expressiveness among mutually supportive family members facilitates this process. If the child’s life is further disrupted by economic hardship or changes in school, home, and friends or the child’s relationship with the deceased parent had been conflictual, the risk of significant adjustment problems may be increased.

Adoption

Adopted children are overrepresented in psychiatric treatment settings because of factors such as genetic or prenatal risks from the birth parents; disruptions, trauma, or neglect in the child’s early life; adoptive home problems (such as unrealistic expectations by both the adoptive parents and the child, differential treatment by parents or grandparents); and the child’s unresolved feelings about being given up for adoption or identity issues. The understanding of temperament (see Chapter 2, “Evaluation and Treatment Planning”) emphasizes the importance of “goodness of fit” between parent and child. To the extent that there is a genetic contribution to temperament, adopted children may be more likely to be mismatched with one or both parents, increasing the risk of behavior and emotional problems.

Children adopted past infancy are at higher risk for psychiatric problems as a result of the experiences that led to placement for adoption. These children have endured not only the loss of their parent(s) or primary attachment figure, but perhaps also neglect, abuse, and frequent changes of caregiver. Some children adopted after spending their first years in a residential nursery or orphanage are capable of forming stable affectionate relationships with their adoptive parents, but many show significant social and attentional problems and attachment difficulties.

It is normal for children and adolescents, even those who have not been adopted, to go through stages of questioning whether they are with their “real” parents and whether another set of parents would be better. It is important for adoptive parents not to take these stages too seriously or personally. Although there is not a clear consensus of when the best time is to disclose to a child his or her adoption status, the child’s cognitive functioning should be taken into account. The trend is increasingly toward “open” adoption, where children are told early and there may be contact with the birth mother.

Demographics

By age 15, 15% of unmarried adolescents have had sexual intercourse; by age 19, 46% have. In 2015 data reported by the CDC, the birthrate among U.S. females ages 15–19 was 22.3 per 1,000, an all-time low, although remaining higher than in other industrialized nations. The recent sharp decline in American teenage pregnancy and birthrates is attributable to increased use of contraceptives, particularly use of highly effective methods (Lindberg et al. 2016). The proportion of teen pregnancies ending in abortion continued to decline, to 30% of pregnancies in 2010. There are large disparities by state of residence and by race, with adolescent girls of color at higher risk for unintended pregnancy.

The Mother

Adolescents who become pregnant are not a uniform group; they differ by race, socioeconomic status, and age. In studies controlled for academic aptitude and financial status, teenage mothers are less likely to complete high school, less likely to achieve a stable and well-paying job, more likely to be dependent on public assistance, and less likely to enter a stable marriage than their peers. Interestingly, those who are able to finish high school, avoid another pregnancy in their teens, and marry do not show negative effects at long-term follow-up when compared with peers who delayed their first pregnancy.

The Child

Lack of adequate prenatal care is a risk factor for prematurity, low birth weight, and neonatal mortality, especially for mothers younger than age 15 years. Children of teenage mothers have higher postneonatal mortality rates and more subsequent illnesses and injuries.

Children, especially sons, of teenage parents appear to be at a developmental disadvantage and may be at higher risk for emotional problems, ADHD, aggression, school failure, and incarceration. The daughters of adolescent mothers are more likely to become pregnant before age 18 years than offspring of mothers in their 20s. Poor prenatal care, genetic factors, parental limited education, and suboptimal parenting because of immaturity, financial stresses, and living in disadvantaged neighborhoods with low-quality schools may contribute to these outcomes.

Interventions

Mental health providers should regularly assess adolescents for high-risk sexual activity and provide guidance on abstinence, consent, contraception, and prevention of sexually transmitted disease. Potential effects of psychotropic medications on a developing fetus or newborn must be reviewed with all adolescents of reproductive potential.

Once an adolescent becomes pregnant, nonjudgmental support for the young woman and her family, along with practical and educational assistance, may facilitate making an informed decision among adoption, abortion, and raising the child. Young mothers are most satisfied with the outcome of their pregnancy when they receive parental support for their decision (Siegel and Brandon 2014). For teenage mothers raising a child, outreach programs offering prenatal care, child care, parenting training, assistance in completing high school, further academic or vocational training, and enrichment programs such as Head Start for the children can positively affect long-term outcome.

Clinical Description

Body mass index (BMI; weight in kg/height in m²), the most appropriate measure to screen for childhood obesity, has norms by age and gender. Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile of age- and sex-specific norms. Obesity is defined as a BMI greater than the 95th percentile.

Epidemiology

The prevalence of childhood obesity is increasing. Data from the 2011–2014 National Health and Nutrition Examination Survey (NHANES) found 17% of youth to be obese (Ogden et al. 2016). African American youth and Hispanic boys are at greatest risk for both obesity and overweight.

Etiology

Genetic, medical, family, and societal factors contribute to the development of obesity. Parental obesity greatly increases the risk. Feeding practices from infancy impact later weight gain. The ubiquitous presence of calorie-dense and nutrition-poor foods, the relative absence of fresh fruits and vegetables in urban “food deserts,” the challenges of exercise in many neighborhoods, and the increase in screen time for many children are all implicated in pediatric obesity.

Evaluation and Differential Diagnosis

The mental health provider may be part of a multidisciplinary team working with the obese child and his or her family. Comprehensive assessment should include medical, family, social, nutritional, physical activity, and sleep history, as well as a physical exam and laboratory tests as indicated to assess metabolic risk factors and possibly rare endocrine or genetic causes of obesity. The nutritional history includes not only what and how much the child consumes but behavioral patterns as well, including where the child eats and with whom; times of day; accompanying activities; emotional state before, during, and after eating; and family attitudes toward food, exercise, and weight. Clinicians must strive to avoid communicating weight bias or shame, respectfully taking into account cultural and socioeconomic factors that influence health and diet behaviors.

Treatment

The treatment team should emphasize family-based efforts rather than targeting the identified patient and make the primary goal healthy behaviors rather than weight change. For children, the medical recommendation is generally to stabilize weight and allow the child to grow into it, rather than weight loss. Prescribing dietary or behavioral changes is less effective than collaborative treatment. Collaboration begins with motivational interviewing, in which the clinician helps the child and family develop their goals and assess their readiness for, and obstacles to, meeting them.

Specific treatment plans vary based on the family presentation, the child’s needs, and resources available, but experts make the following general recommendations (Children’s Hospital Association 2012):

For individuals:

1. Use a hunger scale to develop awareness of hunger and satiety.
   
2. Review and encourage sleep hygiene, as poor sleep is associated with overeating.
   
3. Recommend eating in a common area, such as the kitchen table, without television screens or other distractions.
   
4. Consume five small meals per day.
   
5. Recommend leaving the table after a normal meal and waiting 20 minutes before second helpings, giving time to experience satiety.
   
6. Encourage regular exercise.
   
7. Decrease sedentary activities.

For caregivers:

1. Recommend that the whole family participate in health and exercise behaviors, and explore barriers to these.
   
2. Show love and nurturing without using food as a reward.
   
3. Create a positive family culture around eating.
   
4. Foster mindfulness around eating, encouraging children to enjoy foods and to attend to the sensory experience of eating.
   
5. Avoid buying foods that family members overeat.
   
6. Avoid nagging or criticizing around food—this is likely to be counterproductive.

Certain behavioral patterns related to diet and nutrition may be best addressed in CBT, interpersonal psychotherapy, or DBT. These include boredom eating, emotional eating, binge eating, nighttime eating syndrome, hoarding or hiding foods, and food aversions.

Children who are treated with certain psychotropic medications, particularly the atypical antipsychotics and the mood stabilizers, are at risk for medication-induced weight gain. Counseling regarding dietary habits must be part of their care, and the continued need for treatment must be carefully balanced against the risks associated with development of obesity. Addition of metformin may mitigate medication-induced weight gain (Zheng et al. 2015).

Bariatric surgery is increasingly used to treat severe obesity in adolescents who have not responded to more conservative weight loss strategies, particularly when there is comorbid diabetes or metabolic syndrome. Bariatric surgery can reverse these disease processes (Mirensky 2016).

Developmental Factors in Reaction to Acute Illness, Hospitalization, and Surgery

The emotional response to illness is dependent on the child’s stage of development, the amount of discomfort, the type of treatment and its side effects, the practical limitations that result from the illness, premorbid psychiatric problems in the patient, and the child’s level of understanding. Parents influence the child’s reaction through their own coping mechanisms and the support they are able to provide. Clinicians can often predict the most stressful times in the course of an illness and should take these opportunities to provide additional emotional support. Practices such as parental rooming-in, unlimited parental visiting, permitting parents to be present while the child is sedated preoperatively, and outpatient surgery to avoid hospital admissions have reduced emotional aftereffects. The use of primary nurses and child development specialists in the hospital has also facilitated children’s adjustment. Preparation, individualized to coping style and developmental level, may be done via talks explaining procedures, visits, books, puppet shows, and films.

Chronic Illness

Adherence to Treatment

Lack of adherence to or compliance with medical procedures and regimens can be a major problem in the care of children and adolescents. Factors in the child and parent, family dynamics, the nature of the treatment, and the relationship between the child and family and the medical team can all contribute to poor adherence. Severe nonadherence may warrant a full psychiatric evaluation and treatment of psychiatric disorder(s) and/or family dysfunction.

Adherence is facilitated by giving the child or adolescent as much responsibility for the treatment as appropriate, gradually increasing responsibility as interest, understanding, and behavior control improve. The child should participate in decision making and be offered as many choices as possible. Explanations can be targeted to the child’s ability to understand. The normal compulsiveness of children ages 6–12 years can be harnessed to develop a habit of charting or record keeping related to the treatment. If children or adolescents are able to develop their own relationships with medical personnel, adherence may be facilitated by avoiding the struggles for independence inherent in the parent–child relationship. Adults should minimize power struggles and, whenever possible, negotiate and solve problems with the young person. At times, a child’s nonadherence may signal a parent’s ambivalence about or even opposition to treatment.

Treatment

Risks and Resilience

Children of psychiatrically ill parents are at increased risk for developing a psychiatric disorder themselves, due to both genetic and environmental risk factors. Psychiatric illness in a parent can impact his or her parenting abilities, create marital discord, and disrupt the family environment. Poor decision making or decreased functioning may result in inadequate supervision or neglect. Family disruption may lead to divorce or placement of the child outside of the home. A population-based study in Denmark found that children of parents with schizophrenia, bipolar disorder, or depression were less likely to live in a nuclear family and more likely to live in a single parent–headed household. There was also an increased risk of living with neither parent, especially if a parent has schizophrenia (Ranning et al. 2016). The risk of psychopathology in the child is related to the severity and chronicity of psychiatric illness in the parent.

Children may be particularly distressed when their parents are admitted to a psychiatric hospital. Younger children may show sleep disturbance, decreased appetite, attention-seeking behavior, separation anxiety, crying (especially at bedtime), and social withdrawal. Adolescents are better able to verbalize their fears, guilt, and concerns about themselves and their parents.

Children whose parents are depressed are at increased risk for the development of psychopathology, as well as behavioral, academic, and health problems. Parents who are depressed may be less affectionate and emotionally unavailable to their children, often resulting in elevated rates of depression in their children. These children are more likely to experience a variety of internalizing symptoms, including recurrent feelings of guilt, interpersonal problems, and difficulties with attachment. Remission in maternal depression with treatment is associated with a decrease in symptoms in the child (Weissman et al. 2006).

A 7-year longitudinal study found that 75% of children of a parent with bipolar disorder qualified for a psychiatric diagnosis, most commonly bipolar spectrum disorder, substance use disorder, anxiety disorder, disruptive behavior disorder, or ADHD (Axelson et al. 2015). Children who have a parent with schizophrenia are more likely to have abnormalities in attention and information processing, even before any overt symptoms emerge. Children of patients with anxiety disorders are at increased risk of an anxiety disorder themselves, as well as fears and worries, school difficulties, somatic complaints, and social isolation.

A significant minority of children of alcoholic parents have increased behavior problems, especially conduct problems, hyperactivity, impulsivity, hypersensitivity to stimuli, poor self-control, inattention, and emotional symptoms such as anxiety and depression. Prenatal alcohol exposure is a common nongenetic cause of intellectual disability and can contribute to the development of learning, language, and behavioral disabilities. Children of alcohol abusers are more likely to develop alcohol use problems themselves, and the disinhibition associated with substance use places them at greater risk for suicide, accidents, unplanned pregnancy, HIV exposure, and school failure.

Some “resilient” children not only resist and cope with unusual stress but also thrive and succeed despite adversity. Protective factors include a cohesive and emotionally supportive family environment and external support systems, such as caring extended family members, other adults, and/or institutional supports (e.g., school or community agencies). These children often have a strong commitment to extracurricular activities and interpersonal relationships and tend to be confident and self-reliant. They are realistic in their assessment of the family and its limitations, and understand their own coping style when dealing with parental psychiatric illness.

Adolescence is a particularly high-risk period for the development of major depression in the offspring of parents with mood disorder. Successful adaptation is characterized by close, confiding relationships; persistence and success in school and work; and involvement in activities. They are able to separate themselves, cognitively and emotionally, from their parent and their parent’s illness, while often functioning as caregivers in the family. Coping skills include accurate cognitive appraisal of the stress to be dealt with, realistic assessment of their responsibilities and powers, and an understanding of the parent’s illness (especially that they are not responsible for their parent’s depression).

Interventions

Parents can promote resilient traits in their children and moderate the emotional consequences of their psychiatric illness. Communication between spouses and among family members can improve the level of understanding and reduces guilt and emotional distress. Children should be referred to appropriate support groups. Individual strengths in the child should be encouraged and nurtured. When parents are receiving psychiatric treatment, the treating clinician should be alert to possible effects of the illness on the children. Parental psychiatric hospitalization is particularly stressful. There should be at least one family session near the time of admission to explain the need for hospitalization and the anticipated treatment course. Optimally, a member of the treatment team interviews each child to assess developmental level, school performance, peer relationships, coping skills for dealing with and understanding parental illness, and the possible presence of psychiatric symptoms. Efforts can be made to enrich and strengthen the child’s support system. Placement with a relative or in foster care may be necessary until the parent can resume child-care responsibilities.