WPA guidance on the protection and promotion
of mental health in children of persons
with severe mental disorders
Ian BrockIngton1, PraBha chandra2, howard duBowItz3, davId Jones4,
suaad Moussa5, JulIet nakku6, IsaBel Quadros Ferre7
The United Nations (UN) Convention on the Rights of
the Child (1) affirmed that the child, for the full and harmo-
nious development of his/her personality, should grow up in
a family environment, in an atmosphere of happiness, love
and understanding. Nations must take appropriate mea-
sures to protect the child from all forms of physical or men-
tal violence, maltreatment or exploitation, while in the care
of parents or other persons entrusted with their care. This
Convention was adopted by the UN General Assembly in
November 1989, and has been ratified by 192 nations. It is
not only because of this authoritative pronouncement, but
also because the ambition of medicine is to prevent disease,
that the issue of the mental health of children of mentally ill
parents is important: a promising preventive strategy is to
work with high risk groups, such as these vulnerable chil-
Most of these children are born and reared in low-income
nations, which have a dearth of resources and also, in some
cases, of essential knowledge. There is a paradoxical rela-
tionship between wealth and birth rates: nations in Europe,
North America and elsewhere, with advanced health sys-
tems and strong scientific contributions, have fewer than 10
million births/year. We are concerned not only to improve
practice in these nations, but also and especially to find solu-
tions for those countries in which the other 125 million in-
fants are born. Thus, we seek to recommend state-of-the-art
1Lower Brockington Farm, Bredenbury, Bromyard, Herefordshire, HR7 4TE, UK; 2National Institute of Mental Health and Neurological Sciences, Bangalore, India;
3Division of Child Protection and Center for Families, University of Maryland School of Medicine, Baltimore, MD 21201, USA; 4Department of Psychiatry,
University of Oxford at Warneford Hospital, Oxford, OX3 7JX, UK; 5Faculty of Medicine, Cairo University, Egypt; 7Makerere University, Kampala, Uganda;
8Universidad del Valle, Bogotà, Colombia
This guidance details the needs of children, and the qualities of parenting that meet those needs. Parental mental disorders can damage the
foetus during pregnancy through the action of drugs, prescribed or abused. Pregnancy and the puerperium can exacerbate or initiate mental
illness in susceptible women. After their birth, the children may suffer from the social disadvantage associated with severe mental illness.
The parents (depending on the disorder, its severity and its persistence) may have intermittent or prolonged difficulties with parenting, which
may sometimes result in childhood psychological disturbance or child maltreatment. This guidance considers ways of preventing, minimiz-
ing and remedying these effects. Our recommendations include: education of psychiatrists and related professions about the effect of paren-
tal mental illness on children; revision of psychiatric training to increase awareness of patients as caregivers, and to incorporate relevant
assessment and intervention into their treatment and rehabilitation; the optimum use of pharmacological treatment during pregnancy; pre-
birth planning when women with severe mental illness become pregnant; development of specialist services for pregnant and puerperal
women, with assessment of their efficacy; community support for parenting by mothers and fathers with severe mental disorders; standards
of good practice for the management of child maltreatment when parents suffer from mental illness; the importance of multi-disciplinary
teamwork when helping these families, supporting their children and ensuring child protection; the development of child and adolescent
mental health services worldwide.
Key words: Parenting, severe mental illness, mother-infant relationship, substance abuse, childhood mental disorders, child maltreatment,
child and adolescent mental health services
(World Psychiatry 2011:10)
services to those that can afford them, and creative interven-
tions to less prosperous nations.
PARENTING AND THE NEEDS OF CHILDREN
The needs of children, which parenting must address, can
be listed as follows:
ally valued and secure. This will involve comforting, praise,
and considerate, affectionate and loving care.
Encouragement of learning
. This requires quick and con-
tingent responses to the child’s language and questions,
play, support to schooling, and the promotion of social op-
portunities. It is aided by understanding the child’s world,
his/her temperament, strengths and weaknesses, and may
require special skills, for example in handling disabilities.
Guidance and setting consistent boundaries for cultur-
ally acceptable behaviour, aiming to equip the child with
consideration for others, discipline and internal moral val-
ues. This is achieved by supervision and monitoring (pro-
tecting the child from poor role models), coaching, and
(shelter, nutrition, hygiene, clothing and med-
(protection from dangers, including unsafe people).
, so that the child feels uncondition-
World Psychiatry 10:1 - F e b r u a r y 2 0 1 1
rewarding good behaviour. Unacceptable actions are dis-
couraged in a consistent way, providing a model for anger
control and conflict resolution.
A stable family base
for engagement with the wider
Although there is much variation, these needs progress in
phases from birth to adolescence, starting with attachment
to primary caregivers in the first year. From the security thus
provided, the child achieves gradually increasing autonomy,
and starts to develop a sense of self, to recognize and regulate
emotional states, and to discover the limits of personal pow-
er and identity. During the preschool years, an important task
is peer-group integration. Towards the end of the first decade,
the child begins to establish personal preferences, to take
responsibility and develop a sense of right and wrong. Ado-
lescence is marked by psychosexual development and a
gradual move towards adulthood.
The term “parenting” covers the adult activities that meet
these needs, and foster the child’s development into a suc-
cessful adult. “Caregiving” is sometimes preferred, in order to
include adoptive and foster parents, and others, such as
grandparents, who have a substantial role in caring for the
child. Parenting may be disturbed by many factors other than
mental illness, including poverty, adverse events and family
violence or disruption. The neighbourhood may be violent
and deprived, or, in contrast, may have strong cooperative
networks. There are cultural and religious influences such as
attitudes towards family privacy and cooperation, social re-
sponsibility, authority and ethnicity. Violence, war and per-
secution on a national scale provide the most unfavourable
circumstances for caregiving.
RISK FACTORS DURING PREGNANCY
Treatment and prophylaxis of mental disorders
in pregnant women
Most patients with chronic psychoses, and many with re-
current mental illness, are prescribed prophylactic or thera-
peutic drugs, and many women become pregnant when tak-
ing them. Although it is generally advisable to avoid medica-
tion in pregnancy, the risks of stopping it often outweigh the
risks to the foetus. Pregnancy does not usually become de-
tectable before 30-40 days gestation, so that infants conceived
by women on regular drug intake are exposed to teratogenic
hazards. In the case of most psychotropic drugs, this risk is
controversial and slight. But valproate (possibly also carbam-
azepine) can cause neural tube defects and learning disabil-
ity; this risk is reduced, but not eliminated by folic acid. Elec-
troconvulsive treatment can precipitate early labour, prevent-
able by a tocolytic drug. Neonatal toxicity and/or addiction
have been reported in some babies exposed to lithium, anti-
psychotics, antidepressants and benzodiazepines. The risks
to the breast-fed infant have been exaggerated (2).
We focus on ethanol, narcotics and cocaine, which are the
best researched. Exposed infants face many adverse factors:
their parents often have mental disorders (such as depression
and paranoid disorders); they often abuse other drugs; they
suffer from multiple social problems and poverty; many do
not seek antenatal care. The infants may be affected by ma-
ternal malnutrition and infections such as hepatitis, HIV or
venereal diseases. The quality of care, as much as drug ef-
fects, is a strong predictor of outcome.
All three drugs are associated with an increased risk of
short gestation and low birth weight. In addition, some ex-
posed infants are small for gestational age, which carries the
implication of placental insufficiency, not just early arrest of
intra-uterine life. This in itself, without drug exposure, can
result in neurological dysfunction, and possibly language de-
lays and emotional disorders (3).
Selecting some salient points, ethanol, taken in excessive
quantities, may be teratogenic, causing a general increase of
congenital abnormalities. There may be microcephaly and
permanent brain damage; foetal alcohol syndrome is a lead-
ing cause of mental retardation. A notable complication of
narcotic addiction is the withdrawal syndrome, against
which methadone maintenance does not protect. A specific
complication of cocaine abuse is placental abruption. The
long-term effects of both opiates and cocaine have been
much studied, but without reaching a consensus on cognitive
deficits or behavioural problems, when controlled for social
Other harmful influences during pregnancy
There are claims that subclinical anxiety, depression or
stress during pregnancy can have lasting effects on the child.
They include pregnancy complications, prematurity, low
birth weight or intra-uterine growth retardation, foetal or
neonatal distress, and developmental delay, but there is no
consensus on these effects. Perhaps the best supported claim
is that mid-trimester anxiety affects mental health in mid-
childhood, but such investigations are plagued by many con-
founding factors. Only rigorously designed cohort studies
can substantiate these claims.
Domestic violence during pregnancy carries the risk of
foetal injury and death. It can also severely affect maternal
attitudes and morale.
Many pregnancies are unplanned, but most of these are
merely mistimed, and are fully accepted. A minority remain
persistently unwanted. The number of these unwelcome
pregnancies is much reduced in nations that allow termina-
tion of pregnancy; even so some are carried to term. Un-
wanted pregnancy is a significant problem in many low-in-
come countries (5). It is associated with an increased risk for
denial of pregnancy, foetal abuse, neonaticide, depression,
mother-infant relationship disorders and emotional disor-
ders in children. Cohort studies of unwanted pregnancy and
its psychological outcomes are a research priority.
DISTURBANCES OF PARENTING DUE
TO MENTAL DISORDERS
The complex functions of parenting may be disrupted, to a
greater or less extent, by all forms of parental mental disor-
ders. It is not so much the diagnosis that confers the risk, but
the severity and chronicity of psychopathology. It is important
to emphasize that investigations of parenting report statistical
associations in large samples. There is much variation in psy-
chopathology (its severity and duration), and in each patient’s
personality, coping and social circumstances. Many parents
with severe depressive, anxiety or eating disorders, and even
those suffering from psychosis, make excellent caregivers.
Different disorders have their effect through common
the form of worrying, obsessional or angry ruminations or
delusions, can impair vigilance and the readiness to re-
spond to the child; so this effect will be seen in anxiety,
obsessional and querulant disorders, as well as psychoses
and emotionally unstable personality disorders. Inatten-
tion is also caused by involvement in time-consuming mor-
bid activities, such as compulsive rituals, bingeing or drug
abuse. It will result from disorders affecting the faculty of
attention itself, such as depression. If this withdrawal of
attention is frequent and prolonged, boundary setting will
be inconsistent, and the environment will be impoverished,
without the stimulus to intellectual growth.
. This ranges in severity from
avoidance of the child due to a child-focused phobia or
obsessions of infanticide, to extreme withdrawal seen in
severe depression or psychosis.
. This is prominent in depression, acute psychosis,
mania, intoxication and withdrawal from drugs or alco-
hol. Irritability can find an outlet in the children, who are
more accessible than husbands or other relatives. Patho-
logical anger is a manifestation of severe mother-infant
relationship disorders. Hostility may be targeted on the
child in delusional disorders. Explosive irritability is a
problem for some people with personality disorders.
. A child may be exposed to impul-
sivity, extreme mood swings, bizarre utterances or behav-
iour based on delusions. Abnormal emotional responses
may disturb the interaction. This is perplexing, sometimes
frightening. The shift from institution to community treat-
ment in some countries means that more children experi-
ence psychotic behaviour at close range.
. Any preoccupation, whether in
Parenting is also affected indirectly by other factors:
. Mental illness has a general association with
social adversity (6), which may contribute to its causation,
or may result from illness, disability or social incompe-
tence. For example, mothers with chronic psychosis (who
have a similar number of pregnancies and births to other
women) more often have to cope with single motherhood,
marital discord, domestic violence, poverty and homeless-
ness. They are vulnerable to discrimination and exploita-
tion. More experience rape, and face consequences such
as abortion or sexually transmitted diseases. More have
unwanted pregnancies. More are socially isolated and
lack help in child-rearing. More have partners with mental
disorders. The children may have a higher genetic risk,
and are more likely to have challenging behavioural prob-
lems. These associated factors, taken singly or together
(without the addition of maternal psychosis) increase the
risk of mental disorders in the children.
. The parent-child relationship may be severely
interrupted by parental hospitalization. Even with optimal
treatment, these parents lose contact with their children
for short or long periods, and this may affect attachment.
The child may be traumatized by seeing his/her parents
taken away or living in hospitals. The child will often have
to be transferred to relatives, or foster care, so that he/she
receives multiple parenting. Where there is neither state-
provided foster care nor support from the extended family,
parenting will be inadequate. In addition, mentally ill
women fear the forced removal of their children. Many do
in fact lose them – to estranged husbands, other relatives,
foster care or adoption – and this is a source of prolonged
sadness (7). Fear of losing custody or access dominates
interaction with mental health and social services. Women
may fail to seek help, or fail to disclose that they are par-
ents, because of this fear.
. On account of the parental illness, the child may
be exposed to teasing, bullying and ostracism. The parents
also suffer from stigma, which may lead to social isolation
that increases the adversity of the child’s background.
IMPACT OF SOME SPECIFIC MENTAL
DISORDERS ON PARENTING
In parents with chronic psychosis, caregiving is often er-
ratic and intermittent, with a low quality of sensitivity and
involvement (8). In parents with recurrent and acute psy-
chosis (including post-partum episodes), the parental rela-
tionship is often normal after recovery (9), unless the epi-
sodes are frequent and prolonged.
Depression is the commonest mental disorder, especially
in women of child-bearing age. There is much concern about
World Psychiatry 10:1 - F e b r u a r y 2 0 1 1
its impact on mothering, and many studies have investigated
its effects on mother-infant interaction and child develop-
ment, using various modalities of investigation. Infant tem-
perament and behaviour may also affect maternal mood,
creating a vicious cycle. Nevertheless, adverse effects are not
universal: some depressed mothers are sustained by the in-
teraction with their children (10).
The effects of depression on parenting include the follow-
Depressed parents communicate sadness and pessimism.
They lack laughter and gaiety, and are often irritable. They
may show less affection, tenderness and responsiveness.
These harmful influences have most impact in infancy,
when contact is close and continuous.
Depressive anergia reduces the efforts parents can make.
There may be a reduction in the quantity, quality and va-
riety of interaction. Thinking is inefficient, and, together
with brooding and morbid preoccupations, reduces atten-
tion, resourcefulness and control.
Depression (or associated relationship disorders) may be
associated with language delays and, through their perva-
sive influence, other educational deficits.
There may also be effects on physical health and develop-
ment (11). There are conflicting reports from Brazil, India,
Ethiopia, Vietnam, Pakistan and Peru on an association of
maternal depression with low infant weight and malnourish-
Mother-infant relationship (attachment) disorders
The growth of the mother-infant relationship is the key psy-
chological process in the puerperium. It is this relationship,
gradually developing during the first few weeks after the birth,
which enables mothers to make sacrifices, maintain vigilance,
and endure the toil of nurturing their babies. There is a pathol-
ogy of this process, even before the birth. In rejected pregnan-
cies, the foetus may be viewed as an intrusion, resulting oc-
casionally in foetal abuse (12). After the birth, a disappointing
lack of feeling for the baby (which is common in the early
stages) may, in a small proportion, progress to aversion, hatred
and rejection (13). Maternal hostility deprives the infant of the
fundamental need for loving relationships, severely impairs
interaction, and leads to emotional abuse. The infant’s de-
mands provoke aggressive impulses which, when self-control
gives way, lead to verbal abuse and rough treatment. These
children are at high risk of maltreatment.
Anxiety disorders may affect parenting. Intrusion and ex-
cessive control, “catastrophizing” (predicting dire conse-
quences of normal adventures) and overprotection, some-
times coupled with a lack of warmth and responsiveness,
may deprive children of opportunities to explore and ma-
nipulate the surrounding world. These can lead to separation
anxiety, school refusal and social limitations.
If an expectant mother severely restricts her intake, the
foetus can suffer from impaired nutrition and growth. The
attitudes of some anorexic or bulimic mothers lead to meal-
time conflict, and occasionally to chronic hunger and im-
paired growth (14).
Parenting by women with learning disability is becoming
more important, as they are transferred from institutions to
the community. They are often socially isolated, and have
many other problems. Their children may be at increased risk
of abuse and neglect, but there is a dearth of information on
parenting by these persons.
THE HARM TO CHILDREN WHICH MAY RESULT
FROM PARENTAL MENTAL DISORDERS
Childhood psychological disturbance and mental disorders
Children of persons with severe mental disorders are at
increased risk of psychological disturbance, not only because
of parenting problems, but also because they may share a
genetic predisposition, and be exposed to a slate of back-
ground factors associated with parental mental illness. These
include antecedent obstetric complications, deprivation and
lack of social support, marital conflict and chaotic family life.
They are more vulnerable to exploitation. There is the recip-
rocal effect of challenging child behaviour, provoking paren-
tal hostility. On the other hand, protective factors may be at
work, such as the resilience of the child or the beneficial in-
fluence of a healthy partner or another family member.
The child’s mental health and social competence is best
predicted by multiple contextual risks, less by illness vari-
ables and least by categorical diagnosis. It is widely believed
that parent-child relationships lacking in nurturance and
marked by harsh discipline and especially maltreatment are
important factors in poor cognitive, behavioural and emo-
tional outcomes. A focus on parenting offers excellent op-
portunities for intervention.
Some early forms of infant disturbance can confidently be
related to parenting. They include the states of fear found in
severe abuse. These children have behavioural stigmata: apa-
thy to the point of stupor, crying only in extremis, lack of
expression and vocalization, excessive visual awareness
(“frozen watchfulness”) (15).
Another early manifestation is the distress noticed in in-
fants of depressed mothers. The infant plays an important
part in the developing relationship with his/her caregiver,
contributing to a dialogue through gazing, smiling, laughing
and babbling. He/she is distressed by the failure of these
At the end of the first year, attachment disorders may be
recognized. Secure attachment may signify an enduring ca-
pacity to form relationships, predicting popularity and ac-
ceptance by peers, which in turn promotes other forms of
social competence. Disorganized attachment may be related
to neglectful and abusive parenting. Reactive attachment
disorder of infancy and early childhood is a clinical disor-
der seen in the first five years, marked by persistent abnor-
malities in peer and other relationships. There is a disinhib-
ited variant, with indiscriminate sociability, associated with
In later childhood, there may be “externalizing” syn-
dromes (hyperkinetic, conduct and oppositional/defiant dis-
orders). Claims that parenting is implicated in attention-def-
icit/hyperactivity disorder (ADHD) are controversial, but
children exposed to drug abuse or suffering maltreatment
may be at increased risk. Conduct disorders, and disobedi-
ence in the first decade, grade into teenage delinquency, adult
antisocial traits and offending. Although there are many
competing aetiological factors (including genetic), much re-
search has found an association of these disorders with par-
enting (16). The style most clearly related is authoritarian:
rigid, harsh parenting, and an atmosphere of hostility and
criticism, lead to a vicious circle of misbehaviour and punish-
ment (17). The child’s aggression is learned from the parent.
It becomes part of a web of risk factors leading to further
social disadvantage, provoking negative reactions, under-
achievement, problems in social relationships and future
parenting, mood disorders and substance abuse, as well as
There may be also “internalizing” syndromes, depression
and anxiety. A diagnosable syndrome of depression can be
recognized in later childhood. There is much evidence of
increased depression, and teenage parasuicide, in the off-
spring of mentally ill parents. Parental depression has many
disadvantages for children, which include problems in self-
esteem and peer relationships. But these may be related to
“family risk factors” (such as marital and parent-child dis-
cord) in addition to, or instead of, maternal depression itself
(18). There is extensive literature on the influence of parental
anxiety on the development of morbid anxiety in children.
The transmission of anxiety across generations is partly ge-
netic and partly through modelling and overprotection.
In the teenage years, substance abuse becomes prevalent
in vulnerable adolescents, more so in the children of addicts.
Genetic factors may partly explain the association, but lon-
gitudinal studies have shown that parenting is also impor-
tant, through ineffective discipline, lack of supervision and
monitoring, low levels of support, parent-child conflict and
learning by example.
Child physical abuse
Child physical abuse may be especially associated with
aggressive personalities, but also with psychosis (19), alco-
holism (20,21) and depression (20-22).
Child neglect is defined as the persistent failure to meet a
child’s basic needs and rights, resulting in serious impair-
ment of health or development (23). It may complicate se-
vere depression, psychosis (19,24) and substance abuse
Neglect is a heterogeneous phenomenon with varied mani-
festations, including a failure to prevent suffering or seek
medical or mental health care, lack of clothing, lack of super-
vision, leaving the child with unsafe carers, or deliberate de-
nial of education or social opportunities. It is important to
distinguish it from the unavoidable consequences of poverty:
children in poor, single parent families with many social
problems may be neglected despite the parents’ best efforts.
This applies to nutrition: “failure to thrive” should not be
attributed to neglect without positive evidence. Neverthe-
less, extreme examples, such as severe global neglect and
death from deliberate starvation, and the syndrome of “de-
privation dwarfism”, show that nutrition can also be involved
Emotional neglect and abuse
Emotional maltreatment is a manifestation of severe dis-
orders of the parent-child relationship. “Emotional neglect”
means that mothers are emotionally distant and unrespon-
sive to the child’s need for comfort and help. “Emotional
abuse” includes persistent belittling and humiliation – hos-
tile, critical or sarcastic comments, conveying to children
that they are worthless and unloved, scapegoating, isolating,
ignoring, exploiting or “terrorizing” the child, such as by
threatening suicide or abandonment (27). Exposure to do-
mestic violence can be put under this heading. Emotional
maltreatment may be a more potent risk factor for later mal-
adjustment than other forms of abuse (28).
Munchausen’s syndrome by proxy
This term covers caregivers who induce or feign illness in
their children (29). The manifestations include fabrication or
simulation of symptoms, and deliberate induction of illness
by acts such as poisoning, smothering or infecting their in-
World Psychiatry 10:1 - F e b r u a r y 2 0 1 1
Death of the child
This is usually subdivided into neonaticide (murder of
the newborn) and filicide (parental killing of an older child).
In neonaticide, there is usually no formal mental illness, but
rather an emotional crisis marked by panic or rage, but var-
ious forms of impaired consciousness can occur during par-
turition (30), and can never be excluded in solitary deliver-
ies. Filicide is very rare, but of great public concern. It is
often associated with mental illness, especially suicidal de-
pression, but also delusions involving the child, severe
mother-infant relationship disorders and occasionally acute
psychosis, command hallucinations, delirium, or trance
states (31). Some may fear that mentioning this association
of mental disorder will increase stigma, but we believe that
the better strategy is to recognize the risk and take steps to
PROMOTION OF HEALTH IN VULNERABLE CHILDREN
Clinical practice in adult psychiatry
Those responsible for producing the ICD-11 and the
DSM-V, when formulating their multidimensional systems,
should include the obligatory coding of important contex-
tual factors. One proposed specifier is “onset of mental ill-
ness related to childbearing”. We suggest that “parental con-
text” (current care of a child under the age of 18) should be
The UN Convention on the Rights of the Child (1) states
that nations should provide preventive health care and guid-
ance for parents. Current practice in adult psychiatry falls far
short of this requirement. The status, or even the existence,
of children is often not noted. Psychiatrists must be aware
that many patients are parents, and that their children are at
increased risk of psychological problems. Clinicians must
adapt the standard psychiatric history to include questions
about parenting, marriage and family life. These must be in-
cluded in mainstream training programmes for mental health
We suggest, as a preliminary probe, “Are you looking after
a child?”, followed by “How are you managing as a parent?”
or “Do you have any worries about the care you can provide
for (name of child)?”. In those with childcare responsibili-
ties, there should be a brief parenting assessment, as outlined
in Table 1. This takes some time, but sets the stage for family
support and interventions.
Visiting facilities in hospital
During admission, facilities must be provided for visiting
by the children, shielded from interaction with other patients.
The sick parent may need help in explaining the illness to the
Discharge planning and rehabilitation
This should include educating parents about child devel-
opment and the management of parenting problems. After
discharge, if possible in collaboration with social services,
plans should be made for long-term parenting support in the
community. This could include respite for parents and leisure
opportunities for children. Family status should be moni-
tored to pre-empt a crisis demanding removal of the children.
The UN Convention draws attention to the need for family
planning. When this is in the best interests of the family, this
advice should be a routine part of clinical practice. Schedules
for brief parenting assessment, and remedial programmes,
are subjects for future research. The vignette in Table 2 illus-
trates the management of parenting failure by an overloaded
When a woman with severe mental illness becomes preg-
nant, communication between mental health and obstetric
teams, and other relevant services, is essential. If distance
and resources allow, a multidisciplinary pre-birth planning
meeting should be convened as soon as possible, to share
information and coordinate management. The reason for
urgency is that the interval between the diagnosis of preg-
nancy (which may be delayed) and birth (which may be
premature) can be short. The meeting should include the
general medical practitioner, a representative from the ob-
stetric team, members of the mental health team, and (if
possible) the expectant mother herself. It is helpful to in-
clude the patient’s husband (or father of the child) and a
member of the wider family. There are many issues to be
Table 1 Brief parenting assessment for patients with childcare
A. Evidence that all the children’s needs are being met.
B. If there are problems, further exploration of:
- The quality of the relationship
- Family violence
- Disrupted schooling
- Other problems, such as neglect of safety or health, overprotection or
children taking on a parental role
- Children’s emotional disorders or disturbed behaviour
- Sources of alternative care.
C. Available supports – the other parent, the extended family, school,
neighbours, non-governmental agencies or health care services.
addressed: pharmaceutical treatment, antenatal care, early
signs of a relapse, the management of the puerperium and
the care of the infant. It is essential that the mental health
team is alerted as soon as the mother goes into labour. She
will need extra support in child rearing, and the child pro-
tection team may need to be involved. Referral to a special-
ist psychiatric service for pregnant and puerperal women
may be feasible.
Similar pre-conception planning can also be recommend-
ed when a man or woman with mental illness is considering
starting a family.
The UN Convention stipulates that nations should ensure
appropriate prenatal and postnatal health care. Mother-in-
fant (perinatal) services, either as a branch of child psychiatry
or a subspecialty of adult psychiatry, have developed in a few
high-income countries, and also in India and Sri Lanka.
They can serve a population, handling severe and intractable
illness, training staff, developing services, and conducting
research. Their resources may include outpatient clinics, day
hospitals, inpatient facilities, community outreach, obstetric
liaison, links with other services and voluntary agencies, and
medico-legal expertise. The core of the service is a multidis-
ciplinary specialist team, providing care for the mentally ill
mother and her child – a key resource whatever the cultural
background and the resources available. There is a need for
research into the cost-effectiveness of these expensive “state-
The assessment and management of disordered mother-
infant relationships is one of the skills exercised by these
teams. In all newly delivered mothers who present with
symptoms, it is essential to explore this relationship, bearing
in mind that shame, or fear that disclosure of problems will
lead to the involvement of child protection agencies, often
leads to concealment. Certain tactful probes should be used:
“Have you felt disappointed in your feelings for (name of
child)?” or “How long did it take for you to feel close to your
baby?”. If there is any indication of negative feelings toward
the child, these are explored, together with manifestations of
anger: “What is the worst thing you felt an impulse to do?”,
“Have you ever lost control?”, “What were the worst things
you did to your baby?”. For mothers whose aversion is strong
enough to threaten the health and safety of the infant, inter-
vention is essential. Skillful treatment often achieves a nor-
Services for pregnant women with substance abuse
All members of society should understand that drinking
alcohol, and abusing drugs, can have hazardous conse-
quences, particularly during pregnancy. Practitioners and
midwives should counsel women who are planning preg-
nancy, or are already pregnant, advising them to abstain; they
should be trained to assess abuse in pregnancy. In alcoholism
an issue is the recognition of foetal alcohol effects. In nar-
cotic addiction, reducing the exposure of the foetus is the
aim. Other drugs of abuse should gradually be withdrawn.
Complete withdrawal from opiates, or using an antagonist
such as naloxone, can precipitate a foetal abstinence syn-
drome. For many, replacing heroin by moderate doses of
methadone or buprenorphine is the best option, with less
intra-uterine growth retardation and perinatal complica-
Pregnant addicts require intensive case management. Af-
ter delivery, unsuspected abuse can be detected by markers
in blood, hair, urine, meconium or umbilical tissues. The in-
fants should be kept in hospital for long enough to manage
intoxication or withdrawal symptoms. Early intervention
can alleviate secondary effects, and improve literacy and be-
haviour. There are a few specialist multidisciplinary diagnos-
tic and treatment services (32); their efficacy and worldwide
deployment should be explored.
Table 2 A vignette illustrating parenting assessment
and interventions in a case of severe mental illness in India
A 35 year old widow lived with her son and daughter, aged 7 and 9. Her elderly
father-in-law lived nearby. For 2 years she seldom left the house, confined the
children, neglected their hygiene and fed them on chips and fizzy drinks.
Eventually, when she started screaming at imagined persecutors, neighbours
helped her father-in-law to enforce her hospital admission.
Findings of the parenting assessment:
- The children suffered vitamin deficiencies.
- When they fell ill, their mother failed to consult a doctor.
- They had missed 6 months schooling, and had no playmates.
- Their mother was noisy and unpredictable.
- The elder child took on the parental role, and had to undertake household
- The children’s bond with each other and their grandfather.
- An extended family (alienated by her behaviour).
- Concerned neighbours and school teachers.
The (adult) psychiatry service was the point of delivery for all forms of care.
Despite the lack of a generic social service, there was a social worker attached
to the team. Together with a trainee resident, she undertook the planning of
- The father-in-law was given guidance and physical help in caring for the
children. He agreed to ensure school attendance.
- When the mother’s mental illness was explained, her family became less
critical, and agreed to visit regularly. Neighbours continued to support the
- A teacher monitored the children’s attendance and welfare.
- The children visited their mother. She was instructed in the essentials of
- Since the children were at risk from genetic loading, neglect, single parenting
and unstable childhood, they were referred to the child psychiatry service for
assessment and intervention.
World Psychiatry 10:1 - F e b r u a r y 2 0 1 1
The UN Convention states that child protection should
include programmes to support the child and his/her care-
givers, as well as to identify, report, investigate, treat, follow-
up and prevent child maltreatment. In all actions concerning
children, whether undertaken by administrative authorities
or legislative bodies, the best interests of the child should be
paramount. This, rather than family preservation, is the pri-
mary consideration, and the child’s welfare trumps parental
rights, even when his/her removal aggravates parental men-
tal illness. Nations must pass laws, assigning responsibility,
and setting out the procedures for investigation and reme-
dial action, including emergency protection. Mental health
professionals need to understand the law and the procedures
in the country where they are working.
Child protection requires the alliance of many social insti-
The extended family
mental role of the family, as the natural environment for
the growth and well-being of children. The father’s active
involvement is of great value. Siblings, in-laws and grand-
mothers are often the main sources of support – indeed, in
some countries, the only resource.
Multidisciplinary child protection teams
stay in high-income nations.
In alliance with these teams, or as an alternative,
bourhoods, schools, voluntary agencies and religious
organizations can support families, reporting maltreat-
ment and promoting social opportunities and informal
are the refuge of children who
cannot safely be reared by their biological parents. They
include adoption, foster-parenting and various forms of
. The Convention asserts the funda-
are the main-
Management of maltreatment
The early diagnosis, assessment and management of sus-
pected maltreatment has been summarized elsewhere (33).
When it is associated with severe mental disorder, this intro-
duces a further element of complexity. We take Munchausen-
by-proxy as an example. In this case the parent’s severe psy-
chopathology brings the child’s right to protection into con-
flict with the family’s right to privacy, normal doctor-patient
relations and medical confidentiality. The investigation may
involve reviewing the parent’s medical history (with the gen-
eral practitioner’s help), an unscheduled home visit, covert
surveillance (after wide consultation), and excluding the par-
ent from child care. When the diagnosis is established, the
meeting with the parents is critical: the physician should
make it clear that he/she knows what has been happening,
explain the harm to the child, and assure them that he/she is
going to help them and the child.
Often the only safe remedy is to remove maltreated chil-
dren. Coercive relinquishment is one of the most traumatic
events a mother can experience, and even more so if this re-
sults from a treatable mental illness. It may also be distressing
for the child. Alternative placements also have hazards: the
loneliness and misery of children in orphanages and hospitals
(“hospitalism”) was noted long ago. Foster placements, often
of great benefit, sometimes fail, leading to further disruption.
Much research has been undertaken on the prevention of
maltreatment, through public education and proactive inter-
vention in high risk groups (34,35). Except in so far as some
severe mental disorders (and especially the social environ-
ment associated with them) are risk factors, this is outside the
remit of these Guidelines.
Resources available worldwide
We sought information about resources for child protec-
tion in the nations that contribute most of the world’s chil-
dren. We had the benefit of a series of reports, obtained by
one of us, from 19 countries. We supplemented this by letters
sent to colleagues, asking about laws, public and political
support, national records, reporting, child protection teams,
training, social services and other agencies devoted to child
protection. We obtained answers from six nations in Africa
(Ethiopia, Kenya, Mozambique, Nigeria, Tanzania and
Uganda), three in South-East Asia (India, Pakistan and the
Philippines), two in the Middle East (Egypt and Turkey) and
three in South and Central America (Argentina, Brazil and
Mexico), as well as many high-income nations. A pattern of
four broad groups emerged:
Group 1 consists of prosperous nations, with different
styles and legal arrangements, but everything available –
for example Canada, which has made major contributions
to research on child maltreatment.
Group 2 consists of nations like Turkey and Taiwan, which
may have begun later, but are already making strides to-
wards an effective service. Turkey, for example, has at least
14 child protection teams.
Group 3 consists of countries like India and Uganda, over-
whelmed with children, resourceful but destitute of re-
sources, struggling to establish pioneering units.
Group 4 consists of nations, of which Pakistan is an ex-
ample, where the problem of child maltreatment is at an
earlier stage of resolution (36). A Child Protection Bill is
still awaiting parliamentary action. An obstacle is the
strong culture of family privacy.
We also asked our correspondents what, given their finan-
cial constraints, would improve child protection in their
countries. We only have space for a selection of their re-
sponses, and have omitted the obvious need for more staff
and funding. The first priority was education – “to raise pub-
lic awareness of this very taboo topic” (Pakistan), educating
the populace, school teachers, families of psychiatric patients
and even indigenous healers. The second was improving pro-
fessional training, especially of paediatricians, primary care
teams, midwives and home visitors, who often lack mental
health training. The third was lobbying governments to rec-
ognize these children as a high risk group and take action.
Child and adolescent mental health services
Child and adolescent mental health services are essential
for the promotion of mental health in vulnerable children.
They provide treatment for all the disorders previously sum-
marized. They have a role in teaching and training, assess-
ment, liaison with other agencies, research and prevention,
and developing guidelines. In clinical practice, multidisci-
plinary teamwork is optimal, with a focus on the parent, on
the child and on the social and family context of the child’s life.
Many specific forms of psychotherapeutic and psychological
intervention have been developed, including family therapies,
mother and infant psychotherapies, and brief cognitive thera-
py appropriate to the age and stage of child development.
In the course of our enquiries, it became clear that these
services hardly exist in many low-income nations. In 2005,
the World Health Organization published an atlas of child
and adolescent mental health resources, based on responses
from 66 countries. The atlas does not give details of individ-
ual nations, but it is clear that most countries with high birth
rates have limited child and adolescent services. For exam-
ple, Uganda (where 1.5 million children are born each year)
has two outpatient clinics in Kampala, and only one quali-
fied child psychiatrist, dealing mainly with epilepsy and men-
tal retardation. In 37 nations, care is provided by paediatri-
cians, often with no training in mental health. Even the
United States of America is short of child psychiatrists.
One of the research priorities is to investigate best practice
interventions for mentally ill parents and their children, which
are feasible, fundable and culturally acceptable in low-income
nations. This could include the role of extended families in
supporting vulnerable children and their families.
The way forward is long and difficult. It should perhaps
start with the training of a few specialists working alone, but
available for consultation. They can take a lead in public
education and lobbying politicians. They can build up dem-
onstration units and start training programmes. Training can
be directed not only towards future specialists, but also to-
wards professional people who have contact with children
– for example nurses, paramedical staff and teachers – and
other trusted figures in the community, who can be recruited
to assist children in need.
Addressing the needs of children of persons with severe
mental illness requires (in addition to improvements in the
practice of adult psychiatry, community support for the fam-
ilies and collaboration with child protection agencies) a
worldwide increment of services for child and adolescent
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