adolescence: an exploratory study
Van Loon, L. M. A., Van de Ven, M. O. M., Van Doesum, K. T. M., Hosman, C. M. H., & Witteman, C. L. M. (2014). Negative thoughts and feelings about parental mental illness and the relation with problem behavior in adolescence: An exploratory study. Manuscript submitted for publication.
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Abstract
Children of parents with a mental illness are at risk to develop internalizing and externalizing problems. They might worry about their parent, think they are the cause of their parent’s problems, feel ashamed of their parent, and have the feeling that they are the only one with a parent with mental illness. No quantitative studies have so far addressed the relationships between these negative thoughts and feelings and internalizing and externalizing problems in adolescents. This exploratory survey study examined these relations cross-sectionally and longitudinally in a sample of 31 adolescents with a parent suffering from mental health problems. The cross-sectional results showed that negative thoughts and feelings about parental mental illness were indeed associated with adolescents’ problem behavior. The longitudinal results showed that worrying and having the feeling to be the only one predicted internalizing problems one year later, and guilt predicted externalizing problems one year later. These findings represent a first step toward empirically evaluating relationships between negative thoughts and feelings and the development of adolescent problem behavior, and they suggest that it is important to address these negative thoughts and feelings in preventive interventions with these at-risk youth.
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Introduction
Mental illness does not only affect the person suffering from the illness, but also their social environment, and family members in particular. As many people with mental illness are parents, children might suffer as well. They are at risk to develop a range of problems, including internalizing (i.e., anxiety, depression, somatic complaints) and externalizing (i.e., aggression, rule-breaking behavior) problems (e.g., Merikangas, Dierker, & Szatmari, 1998; Weissman et al., 2006). The possible negative effect of parental mental illness on children has been studied extensively, mostly by using parents’ reports. There is much less research that has incorporated children’s perspectives and experiences (Gladstone et al., 2006; Mordoch & Hall, 2002). These perspectives and experiences are important, as children are the ones who really know what it is like to have a parent suffering from mental illness. Insight in children’s negative thoughts and feelings about their parent’s mental illness can be really valuable for designing and improving preventive interventions for these at-risk children.
Children may have a range of negative thoughts and feelings about parental mental illness. For instance, they might worry. Children can have worries about practical things, such as not being looked after or being separated from their parent because they are deemed incapable of caring, and they can also have specific concerns related to their parent’s mental health problems, such as about possible parental suicide, recurring illness, hospitalizations, and unlikelihood of recovery (Cogan, Riddell, & Mayes, 2005; Östman, 2008; Somers, 2007; Stallard, Norman, Huline-Dickens, Salter, & Cribb, 2004). Adolescents can also be concerned about developing a mental illness themselves (Handley, Farrell, Josephs, Hanke, & Hazleton, 2001; Meadus & Johnson, 2000; Riebschleger, 2004).
Another negative thought that children with a parent with mental illness might have is that they can think that they are the cause of their parent’s problems. Children often do not have complete and accurate information about the causes of their parent’s mental health problems (Gladstone, Boydell, Seeman, & McKeever, 2011). Children might therefore feel guilty and blame themselves for their parent’s situations (Fjone, Ytterhus, & Almvik, 2009; Handley et al., 2001; Stallard et al., 2004).
Sometimes children have the feeling that they are the only one who has a parent with mental illness. Adolescents with a parent with mental illness reported that they realized their home situation was different than that of their peers without parents with mental illness (Mordoch & Hall, 2008). Foster, O’Brien and McAllister (2005) found that children of parents with mental illness were unaware of other children in similar circumstances, and that it was helpful to know they are not the only ones in this situation. A qualitative review study (Gladstone et al., 2011) concluded that getting in touch with others in a similar situation is helpful for children; they can identify with others which normalizes their experiences.
Offspring of parents with mental illness might also experience feelings of shame and embarrassment. Fjone and colleagues (2009) found that these feelings particularly occurred in public situations where the parent acted differently from other parents, such as talking too loud or too much. They also found that even when children did not compare their parent to other parents, they still could have a feeling that something was not right in their home situation. Children also reported that parents sometimes displayed inappropriate behavior when they had friends over for the night (e.g., forbidding them to go to the toilet due to parent’s delusion), which could result in never asking friends to stay again.
The abovementioned literature used qualitative research methods (i.e., focus groups, interviews) and, although these studies enhanced knowledge about children’s perspectives, they did not examine the relationship between negative thoughts and feelings and internalizing and externalizing problems of these children with a parent with mental illness. Thus, it is already clear that children of parents with mental illness can experience negative thoughts and feelings about parental mental illness, but it is not known yet whether these thoughts and feelings can affect their problem behavior. To our knowledge, only one quantitative study has addressed the relation between negative thoughts and feelings and problem behavior. This cross-sectional study by Van Santvoort and colleagues (2013) included children aged 8 to 12, and showed that children’s negative thoughts and feelings about parental mental illness were related to more psychosocial problems in these children. The present study aimed to extend this finding by examining the relations longitudinally. Furthermore, the present study examined these relations in a sample of adolescents, as adolescence is an important developmental phase with many transitions on the biological, psychological, social, and economic level (Steinberg, 2011). The main research question in the present study was whether negative thoughts and feelings about parental mental illness predict an increase in adolescents’ internalizing and externalizing problems one year later. It was hypothesized that feelings of worry, guilt, being the only one, and shame are predictive of more internalizing and externalizing problems over time.
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Method
The present study is part of a large longitudinal study of risk and protective factors among adolescents who have a parent with mental health problems. Participants were recruited via general practitioners, mental health institutions, advertisements, schools, and a previous study (Van Santvoort et al., 2014). For a detailed description of the sampling and study procedure, see Van Loon, Van de Ven, Van Doesum, Witteman, and Hosman (2014). The ethics committee of the Faculty of Social Sciences of the Radboud University Nijmegen approved the protocol of this three-wave longitudinal study. Parental mental illness at baseline was based on self-report, and confirmed by either a score above the cut-off level on one of several well-validated questionnaires (HADS: Hospital Anxiety and Depression Scale, Zigmond & Snaith, 1983; GHQ: General Health Questionnaire, Goldberg, 1972; CAGE: problem drinking questionnaire, Ewing, 1984) or by a mental health professional.