Women with schizophrenia as parents
ABSTRACT What are the major issues faced by mothers who suffer from schizophrenia? This article reviews the literature and offers clinical opinions based on 7 years of experience in a specialized service for women with psychosis. The literature indicates that >50% of women with schizophrenia are mothers and approximately 50% of these mothers lose custody of their children at least temporarily. This usually has detrimental implications for both mother and child. Child and adult mental health service providers, as well as child protection workers and family lawyers, need to work cooperatively to ensure the safety and healthy functioning of the mother-child unit in the schizophrenia population.
- SourceAvailable from: Mary V. Seeman[Show abstract] [Hide abstract]
ABSTRACT: The goal of this review is to aid clinicians with ethical issues arising in the treatment of women who suffer from psychosis. This paper is a synthesis of the recent literature in adult and child psychiatry, ethics, law, and child welfare pertaining to the topic of maternal psychosis. Topics include: family planning, the care of pregnant women with schizophrenia, postpartum psychosis, child custody, involuntary treatment, confidentiality issues, and service fragmentation. Appreciation of the particularized circumstances of issues arising in the treatment of mothers who suffer from psychosis serve the clinician better than the dispassionate application of a principle-driven ethic.Archives of Women s Mental Health 08/2004; 7(3):201-10. · 2.01 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: How best to evaluate maternal efficacy when cultural traditions that relate to the postpartum period radically differ?American Journal of Psychiatry 06/2008; 165(5):565-8. · 14.72 Impact Factor
What are the major issues faced by
mothers who suffer from schizophrenia?
This article reviews the literature and offers
clinical opinions based on 7 years of expe-
rience in a specialized service for women
with psychosis. The literature indicates
that >50% of women with schizophrenia
are mothers and approximately 50% of
these mothers lose custody of their chil-
dren at least temporarily. This usually has
detrimental implications for both mother
and child. Child and adult mental health
service providers, as well as child protec-
tion workers and family lawyers, need to
work cooperatively to ensure the safety and
healthy functioning of the mother-child
unit in the schizophrenia population.
An estimated 50% of North American
women suffering from schizophrenia are
parents—a percentage identical to that of
the general population. A recent commu-
nity survey in Great Britain suggested
that the percentage of women with a psy-
chotic illness who are mothers is as high
as 63%.1This proportion may be growing
because psychotic illness is now treated
in the community rather than in institu-
tions, treatment outcomes are improving,
and current antipsychotic medications no
longer raise prolactin levels2and thus do
not interfere with conception.3,4
Since children of schizophrenic mothers
face the prospect of serious psychiatric
illness for environmental and genetic
reasons, psychiatrists can play a major
preventive role by engaging women
with schizophrenia in discussions about
protecting themselves from unwanted
sexual advances, using effective contracep-
tion, and planning responsible parenthood
(Table 1). By ensuring safe pregnancies and
deliveries and preventing postpartum psy-
choses, mental health problems in the chil-
dren can be diminished. Most important is
providing ongoing support and treatment
to the mothers and, at the same time,
monitoring the well-being of the children.
Besides being vulnerable to episodic
symptoms of psychosis, women who suf-
fer from schizophrenia frequently experi-
ence interpersonal problems, mood
problems, cognitive problems, and
behavior problems that interfere with
optimal parenting. The medications that
help control psychotic symptoms induce
sedation and passivity, further contribut-
ing to parenting difficulties.
Mary V. Seeman, MD, DSc
Dr. Seeman is professor emeritus in the Department of Psychiatry at the University of Toronto Centre for
Addiction and Mental Health.
Acknowledgments: The author would like to thank the clients and staff of the Women’s Clinic for Psychosis
for their invaluable input. The research work of the clinic has been financially supported by the
Schizophrenia Society of Canada, the Bertha Rosenstadt Fund (University of Toronto), the Ontario Mental
Health Foundation, the Canadian Psychiatric Research Foundation, Eli Lilly Pharmaceuticals, the Ian
Douglas Bebensee Foundation, and the Donner Foundation.
Primary Psychiatry. 2002;9(10):39-42
© MBL Communications Inc. Primary Psychiatry, October 2002
39-42_1002PP_Seeman 5/4/09 11:48 AM Page 39
Consequent to their illness, women
with schizophrenia abuse alcohol and
other substances more than women in
the general population. They may con-
tinue to do this during pregnancy. They
are often single mothers who are eco-
nomically disadvantaged and alienated
from families and former friends (Table
2). They do not readily make new
friends. This means there is no one to
help look after the children or offer
respite during times of distress. In the
British community study, 22% of
women with children at home rated
themselves as having problems obtain-
ing child care. Thirty-seven percent
expressed a need for company, and 29%
for intimate relationships, which
speaks to the loneliness of these women
and their lack of social supports.1
To add to the problems of social iso-
lation and poverty, mothers with schiz-
ophrenia give birth to children who
may inherit genes for schizophrenia.
This can lead to developmental delays
in the child and increased parenting dif-
ficulty. Smoking, alcohol use, and drug
use during mother’s pregnancy, as well
as the likelihood of inadequate prenatal
care, may predispose these children to
behavioral difficulties even in the
absence of genes that express a vulner-
ability to schizophrenia. About half of
the children of women with schizophre-
nia are known to be born prior to the
mother’s diagnosis.5This may mean
that the mothers are functioning well
during their children’s early years. On
the other hand, it may mean that some
are already functioning poorly but have
not yet come to psychiatric attention.
The family physician is best placed to
intervene in these instances.
Contributing to a lack of prepared-
ness for parenthood, about half of the
pregnancies in women with schizo-
phrenia are unplanned. This statistic is
similar to that of the average amount
of unplanned pregnancies in the
United States. In the schizophrenia
population, 25% of unplanned preg-
nancies are terminated at the mother’s
initiative.5Relatively large percentages
of schizophrenic mothers who choose
to have their children lose custody
of them to their own mothers, the
child’s father, foster homes, or
adoptive parents because of the multi-
ple problems they encounter.6-8
Working in a clinic for women
with psychosis9has allowed a better
understanding of the burdens of par-
enthood in this population, the defi-
ciencies in mothering reported in the
schizophrenia literature, the potential
risks to children,10and the intense
desire on the part of these women to
become competent parents.11-14
The Meaning of Parenthood
Several qualitative studies have
explored the meaning of parenthood to
women with schizophrenia. Sands15
interviewed individual mothers with
chronic mental illness. The majority of
participants in this study were African
Americans from low-income house-
holds. They were asked about their
experiences with motherhood and psy-
chosis, specifically about how their
mental illness affected their mothering.
An emergent theme was the struggle to
maintain custody of children despite
major health problems and secondary
effects of antipsychotic treatment.
Mowbray and colleagues16
interviewing 24 mothers with serious
mental illness. Half of the women
acknowledged feeling badly about their
illness. Parenthood was described
ambivalently as both stressful and
growth-promoting. One fourth of the
mothers reported that disciplining the
children was the number one challenge
of motherhood. Nicholson and col-
leagues17used focus groups to examine
the experiences of severely mentally ill
mothers with young children. They
focused on the quality of social support
the mothers received from family mem-
bers. Results indicated that relationships
with family were complicated, some-
times supportive, sometimes intrusive,
and often perceived as negative. The
major themes that emerged from focus
groups with mentally ill mothers con-
ducted by Bassett and colleagues18in
Australiawere the traumas of loss of cus-
tody, hospitalization, social isolation,
and stigma. Single parenthood was a sig-
nificant theme. These mothers identified
the need for substitute care, better
access to community services, consisten-
cy in care provision, and improved rela-
tionships with their children.
A Canadian study used focus groups
with 28 female participants diagnosed
with schizophrenia and schizoaffective
disorder found that these women felt
isolated and could not initiate relation-
ships.14They understood that antipsy-
chotic drugs could increase parenting
problems and that there was a risk asso-
ciated with taking them during pregnan-
cy, but they were afraid to stop treat-
ment. They reported personal benefits of
being mothers (eg, love, purpose, identi-
ty, support), but these benefits were off-
set by stress, exhaustion, poverty, fear of
losing their children, and fear that their
children may develop schizophrenia.
These mothers relayed feelings of endur-
ing grief and anger following the loss of
children to foster care or adoption. They
expressed needs for support, informa-
tion, and therapeutic programs that
include social activities, substance abuse
counseling, relationship and assertive-
ness groups, and family planning.14
Prevalence of Motherhood
and Custody Loss
Several clinics have reported the
prevalence of motherhood and custody
loss among their clients. Ritsher and col-
leagues19asked case managers to fill out
questionnaires on their entire clinical
population of 419 female clients. They
found that half the women had children
and half of those had retained custody of
at least one child. Of those who were
raising their children, 44% were single.
Over 70% required assistance with child
care.19Joseph and colleagues20adminis-
tered a questionnaire to 32 women with
schizophrenia. Sixty-one percent turned
out to be mothers. While 20% of the
Primary Psychiatry, October 2002 © MBL Communications Inc.
Preventive Strategies for Women
• Sex education
• Prenatal care
• Safe labor and delivery
• Intensive treatment throughout the
• Ongoing support and treatment
of the mother
• Ongoing monitoring of the child
Seeman MV. Primary Psychiatry. Vol 9, No 10. 2002.
Problems Experienced by
Mothers With Schizophrenia
• Lack of interpersonal skills
• Mood fluctuations
• Cognitive difficulties
• Behavioral unpredictability
• Side effects of medications
• Alcohol and other substances
• Lack of social support
Seeman MV. Primary Psychiatry. Vol 9, No 10. 2002
39-42_1002PP_Seeman 5/4/09 11:48 AM Page 40
mothers had retained full custody, only
12% were actually the primary care-
givers. Hearle and colleagues21reported
that 59% of the 110 women in their clin-
ic for schizophrenia were parents and, in
9% of these households, the partner also
suffered from a serious mental illness.
Forty-two percent of the children lived
with their parents.
In a case-control study, Miller and
Jacobsen22found that significantly more
mothers with schizophrenia than con-
trols from similar socioeconomic and
marital backgrounds had children in fos-
ter care (49% versus 2%) and significant-
ly more of the mothers who had custody,
in comparison to control mothers, had
relegated the care of their children to
others (36% versus 9%). These studies
indicate that half the mothers with schiz-
ophrenia and related disorders who are
in treatment have lost custody of their
children at some point, producing dis-
continuities of upbringing for the chil-
dren and intense distress for the mothers.
In the community study, a compara-
tively low figure (10%) of the women with
children had a history of having had a
child in the care of social services, even
temporarily. This is a much smaller ratio
of child loss than seen in the clinical sam-
ples. The reasons for the discrepancy are
that the factors that mitigate against
becoming a clinic client (higher socioeco-
nomic bracket, intact marriage, support-
ive family, absence of substance abuse,
absence of aggressive behavior) are the
same factors that prevent children’s
apprehension by child protecion agen-
cies. Although primary care physicians
can do little to change their patients’
financial or domestic situations, they can
help to prevent substance abuse and they
can help to diminish aggressive behavior
through behavioral and pharmacologic
means. They can also help by organizing,
with child protection personnel, intensive
home-based assistance for isolated
mothers suffering from psychosis, thus
maintaining family integrity in an
environment that is safe for children.
Custody decisions are based on parent-
ing assessments requested by child
protection agencies. Of all psychiatric
diagnoses, schizophrenia is perhaps most
associated with low mother-infant inter-
action scores on assessment scales
designed to predict healthy development
in neonates.23Using the Global Rating
Scales of Mother-Infant Interaction
applied to videotaped interactions of
mothers and 4-month old infants, moth-
ers with schizophrenia were found to be
more remote, silent, verbally and behav-
iorally intrusive, self-absorbed, flaccid,
insensitive, and unresponsive than moth-
ers in the contrast affective disorders
group.24Their infants were more avoidant
and the mother-child
appeared less satisfying than that of the
contrast group.24Another recent study
has underscored the impact of the nega-
tive symptoms of schizophrenia on moth-
medications may be contributory here.
Early parenting assessments are under-
standable from the perspective of child
protection because adoption decisions
are best made during infancy. However,
evaluations carried out during the post-
partum period put biological mothers at a
disadvantage because all psychiatric syn-
dromes, including schizophrenia, are
prone to postpartum exacerbation. This
means the mother will either be very ill or
very medicated when assessed. This is not
a time when her capacity to bond with
her baby can be fairly judged.
Custody decisions made at later
periods rely to some extent on how well
the child is developing. Again, children of
mothers with schizophrenia may suffer
developmental lags and relative failure to
thrive not because of poor parenting, but
as a result of the partial expression of
Such children will benefit from extra
stimulation and an enriched environ-
ment, but this does not necessitate taking
the child away. Extras, such as day care
centers and holiday camps, can be pro-
vided while keeping the child in the
Outcomes in Children of
Mothers With Schizophrenia
An early study where infants were
assessed over a 4-year period suggested
that the specific diagnosis of schizo-
phrenia has less impact on the child’s
development than social status and
severity/chronicity of mother’s illness. In
this study, children of mothers suffering
from depression were found to be more
impaired than children of mothers diag-
nosed with schizophrenia.26
A 3-year study testing young chil-
dren of black, low income, single
mothers, came to a somewhat differ-
ent conclusion.27Mothers were diag-
nosed with either schizophrenia,
depression, or no mental illness. In
most domains of functioning, the chil-
dren of the mothers with schizophre-
nia had the most problems. The child-
rearing environment of the children of
mothers with schizophrenia was char-
acterized by less play, fewer learning
experiences, and less mother-child
emotional and verbal involvement.
Mothers of both illness groups were
less effectively involved with their chil-
dren than were well mothers. The fol-
lowing protective factors were identi-
fied: less severe illness, older age of
mothers, higher education and IQ, a
history of work experience, and the
presence of another adult in the
house.27In a later report on this study,
the authors stated that parenting prac-
tices, not mother’s diagnosis, were the
key to healthy child development.28
In a more recent study, Yoshida and
colleagues29found that infants of moth-
ers with schizophrenia had more motor
and cognitive impairments at 2 and 7
months than infants of mothers with
other diagnoses, but that this could be
fully explained by the infant’s initial birth
weight and the mother’s social class.
Perhaps the more important question is
what happens to these children once they
are adults. Results of the Copenhagen
High-Risk Study (207 children of schizo-
phrenic mothers and 104 control children
followed since 1962) indicated that 16.2%
of the high-risk children versus 1.9% of
the control group developed schizophre-
nia, and another 4.6% developed a related
illness (versus 0.9%).30The rate of mood
disorder was the same in the both groups.
These findings are expected from what we
know about the genetic transmission of
Twenty-five of the Copenhagen chil-
dren of mothers with schizophrenia
who were reared with their mothers
were compared to 25 who were reared
apart. More psychopathology was
found in those reared away from their
mothers. Although the explanation
may lie in the fact that more severely
ill mothers were more likely to have
lost custody so that the reared-apart
children could be said to have inherit-
ed more severe psychopathology, this
finding underscores the fact that rear-
ing by a mother with schizophrenia
© MBL Communications Inc. Primary Psychiatry, October 2002
39-42_1002PP_Seeman 5/4/09 11:48 AM Page 41
does not necessarily lead to a greater
incidence of adult psychiatric illness.31
How to Help
Psychiatric services can best serve
mothers with schizophrenia and their
children by instituting comprehensive
intervention programs. Services need to
be in place prior to the birth of the baby.
For example, women with schizophre-
nia frequently do not avail themselves of
prenatal care.32Their risk for premature
delivery and low birth weight is 50%
greater than that of the general popula-
tion.33,34Adequate prenatal care can, at
least theoretically, reduce the incidence
of schizophrenia in these children.35A
comprehensive service should include
diagnostic and treatment components;
emergency, inpatient, and outpatient
services; outreach to parents and chil-
dren; linkages with schools, camps,
extended families, child protection, and
legal services; and obstetric and pedi-
atric facilities. Among the required
resources are case management out-
reach teams; neuropsychological asses-
sors; parenting capacity assessors; thera-
peutic group leaders; child, adult, and
family therapists; and pharmacothera-
pists. Interventions should include
symptom management, parenting class-
es, addiction treatments, family plan-
ning education, therapeutic nurseries,
support and information groups, occu-
pational and vocational help, homemak-
ing help, and respite opportunities
(Table 3). Income supplementation and
safe housing are also essential. Optimal
care provision for the mother-child unit
requires adult and child mental health,
child protection, and legal service sys-
tems to work cooperatively and preven-
tively toward resolving opposing per-
spectives and keeping families together
Primary care physicians treat many
women living in the community who
suffer from psychotic illnesses. Some of
these women live alone and may
become pregnant or may already
already caring for children at home.
Some may have lost custody of their
children and may be battling the family
legal system for visiting rights or for
regaining custody. The safety of children
needs to be ensured. This may mean
temporary removal of the child from the
home until the mother’s illness is treated
and until a thorough parenting assesess-
ment rules out danger to children.
Maintaining the integrity of the family
unit then becomes the main priority.
Family integrity can be ensured by
good symptom control of the mother’s
psychotic illness (perhaps through
home outreach programs), regular child
monitoring (through the family or child
protection staff), assurance of income
supplementation and adequate housing
for the family unit, and domestic and
respite aid for the mother. The provision
of parent skill teaching, troubleshooting
techniques, and effective role modeling
is important. Family counseling and
support of family cohesion around the
needs of the mother-child unit are cru-
cial services that the primary care physi-
cian is best positioned to offer.●●●
1. Howard LM, Kumar R, Thornicroft G. Psychosocial
characteristics and needs of mothers with psychot-
ic disorders. Br J Psychiatry. 2001;178:427-432.
2. Turrone P, Kapur S, Seeman MV, Flint A.
Elevation of prolactin levels by atypical antipsy-
chotics. Am J Psychiatry. 2002;159:133-135.
3. Miller LJ. Sexuality, reproduction, and family
planning in women with schizophrenia.
Schizophr Bull. 1997;23:623-635.
4. McGrath JJ, Hearle J, Jenner L, et al. The fertili-
ty and fecundity of patients with psychoses. Acta
Psychiatr Scand. 1999;99:441-446.
5. Barkla J, Byrne L, Hearle J, et al. Pregnancy in
women with psychotic disorders. Arch Women’s
Mental Health. 2000;3:1-4.
6. Nicholson J, Blanch A. Rehabilitation for parent-
ing roles for people with serious mental illness.
Psychosoc Rehab J. 1994;18:109-119.
7. Nicholson J, Geller, JL, Fisher WH, Dion GL.
State policies and programs that address the
needs of mentally ill mothers in the public sector.
Hosp Community Psychiatry. 1993;44:484-489.
8. Oyserman D, Mowbray CT, Zemencuk JA.
Resources and supports for mothers with severe
mental illness. Health Soc Work. 1994;19:132-142.
9. Seeman MV, Cohen R. A service for women with
schizophrenia. Psychiatr Services. 1998;49:674-677.
10. Oates M. Patients as parents: the risk to chil-
dren. Br J Psychiatry. 1997;170:22-27.
11. Mowbray CT, Oyserman D, Zemencuk JK, Ross
SR. Motherhood for women with serious mental
illness: pregnancy, childbirth, and the postpar-
tum period. Am J Orthopsychiatry. 1995;65:21-38.
12. Zemencuk J, Rogosch F, Mowbray CT. The seri-
ously mentally ill woman in the role of parent:
characteristics, parenting sensitivity, and ser-
vice needs. Psychosocial Rehab J. 1995;18:79-92.
13. Fox L. Missing out on motherhood. Psychiatr
14. Chernomas WM, Clarke DE, Chisholm F. Living
with schizophrenia: the perspectives of women.
Psychiatr Services. 2000;51:1517-1521.
15. Sands RG. The parenting experience of low-
income single women with serious mental disor-
ders. J Contemp Human Services. 1995;76:86-96.
16. Mowbray CT, Oyserman D, Ross S. Parenting and the
significance of children for women with a serious men-
tal illness. J Mental Health Admin. 1995;22:189-200.
17. Nicholson J, Sweeney EM, Geller JL. Mothers with
mental illness: II. Family relationships and the con-
text of parenting. Psychiatr Serv. 1998;49:643-649.
18. Bassett H, Lampe J, Lloyd C. Parenting: experi-
ences and feelings of parents with a mental ill-
ness. J Mental Health. 1999;8:597-604.
19. Ritsher JEB, Coursey RD, Farrell EW. A survey
on issues in the lives of women with severe men-
tal illness. Psychiatr Serv. 1997;48:1273-1282.
20. Joseph JG, Joshi SV, Lewin AB, Abrams M.
Characteristics and perceived needs of mothers
with serious mental illness. Psychiatr Serv.
21. Hearle J, Plant K, Jenner L, et al. A survey of
contact with offspring and assistance with child
care among parents with psychotic disorders.
Psychiatr Serv. 1999;50:1354-1356.
22. Miller LJ, Finnerty M. Sexuality, pregnancy, and
childbearing among women with schizophrenia-
spectrum disorders. Psychiatr Serv. 1996;47:502-505.
23. Hipwell AE, Kumar R. Maternal psychopathol-
ogy and prediction of outcome based on moth-
er-infant interaction ratings (BMIS). Br J
24. Riordan D, Appleby L, Faragher B. Mother-
infant interaction in post-partum women with
schizophrenia and affective disorders. Psychol
25. Snellen M, Mack K, Trauer T. Schizophrenia,
mental state, and mother-infant interaction:
examining the relationship. Aust N Z J
26. Sameroff A, Seifer R, Zax M, Barocas R. Early
indicators of developmental risk: Rochester lon-
gitudinal study. Schizophr Bull. 1987;13:383-394.
27. Goodman SH. Emory University project on
children of disturbed parents. Schizophr Bull.
28. Goodman SH, Brumley HE. Schizophrenic and
depressed mothers: relational deficits in parent-
ing. Development Psychol. 1990;26:31-39.
29. Yoshida K, Marks MN, Craggs M, et al.
Sensorimotor and cognitive development of
infants of mothers with schizophrenia. Br J
30. Parnas J, Cannon TD, Jacobsen B, et al.
Lifetime DSM-III-R diagnostic outcomes in the
offspring of schizophrenic mothers. Results
from the Copenhagen High-Risk Study. Arch
Gen Psychiatry. 1993;50:707-714.
31. Higgins J, Gore R, Gutkind D, et al. Effects of
child-rearing by schizophrenic mothers: a 25-
32. Kelly RH, Danielsen BH, Golding JM, et al.
Adequacy of prenatal care among women with
psychiatric diagnoses giving birth in California in
1994 and 1995. Psychiatr Serv. 1999;50:1584-1590.
33. Bennesden BE, Mortensen PB, Olesen AV, et al.
Preterm birth and intra-uterine growth retarda-
tion among children of women with schizo-
phrenia. Br J Psychiatry. 1999;175:239-245.
34. Sacker A, Done DJ, Crow TJ. Obstetric compli-
cations in children born to parents with schizo-
phrenia: a meta-analysis of case-control studies.
Psychol Med. 1996;26:279-287.
35. Warner R. The prevention of schizophrenia:
what interventions are safe and effective?
Schizophr Bull. 2001;27:551-562.
36. Blanch A, Nicholson J, Purcell J. Parents with
severe mental illness and their children: the
need for human services integration. J Mental
Health Admin. 1994;21:388-396.
37. Cowling V. Meeting the support needs of families
with dependent children where the parent has a
mental illness. Family Matters. 1996;45:22-25.
38. Göpfert M, Webster J, Seeman MV, eds. Parental
Psychiatric Disorder: Distressed Parents and
Their Families. Cambridge, UK: Cambridge
University Press; 1996.
Primary Psychiatry, October 2002 © MBL Communications Inc.
Elements of a Comprehensive Service
for Mothers With Schizophrenia
• Diagnostic, neuropsychological, and
parenting capacity assessments
• Outpatient, home outreach, crisis,
and inpatient treatment
• Individual-, marital-, family-, and
• Parent education
• Extensive linkages with schools, child
protection, and legal services
• Income supplementation
• Safe housing
• Respite and domestic aid
• Treatment accessibility for children
• Emphasis on prevention of negative
impact of the mother’s illness on the
child (ie, prenatal care, good
obstetrics, postnatal psychiatric
care, infant monitoring, and early
intervention with the child
Seeman MV. Primary Psychiatry. Vol 9, No 10. 2002.
39-42_1002PP_Seeman 5/4/09 11:48 AM Page 42