Indian Journal of Psychological Medicine

REVIEW ARTICLE
Year
: 2019  |  Volume : 41  |  Issue : 3  |  Page : 228--234

Children of parents with mental illness: The need for family focussed interventions in India


Divya Ballal, Janardhana Navaneetham, Prabha S Chandra 
 Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Janardhana Navaneetham
Department of Psychiatric Social Work, 1st Floor, MV Govindaswamy Centre, NIMHANS, Bengaluru - 560 029, Karnataka
India

Abstract

Family interventions have been an integral part of mental healthcare in India for several decades. This paper highlights the need for an emerging change in the nature of family interventions in India—from generic interventions for heterogeneous caregiver groups to interventions addressing particular needs based on family stages and structures. It makes a case for recognizing the experiences and needs of one such group, that is, families affected by parental mental illness with children in their care and summarizes the current status of research on this topic in the Indian and global context. It presents implications for future research in India and discusses preliminary ideas for professionals working in adult mental health settings to address the needs of children and families affected by parental mental illness.



How to cite this article:
Ballal D, Navaneetham J, Chandra PS. Children of parents with mental illness: The need for family focussed interventions in India.Indian J Psychol Med 2019;41:228-234


How to cite this URL:
Ballal D, Navaneetham J, Chandra PS. Children of parents with mental illness: The need for family focussed interventions in India. Indian J Psychol Med [serial online] 2019 [cited 2019 Jun 20 ];41:228-234
Available from: http://www.ijpm.info/text.asp?2019/41/3/228/257376


Full Text



The formal involvement of families in mental healthcare in India can be traced back to the 1950s, with pioneering works at the Amritsar Mental Hospital; the Mental Health Centre, Vellore; and the National Institute of Mental Health and Neurosciences, Bangalore.[1] Although these early experiments showed that the involvement of families did lead to better patient outcomes, they also highlighted the burden and stress faced by the families and the importance of providing them support and education.[2],[3]

Since then, rigorous studies have established the effectiveness of family interventions for various psychiatric disorders. These interventions have traditionally included a heterogeneous group of caregivers comprising predominantly of parents and spouses and sometimes, siblings and adult children.

 Recent Trends in Family Interventions in India



In the last few years, there has been an increasing recognition that the needs of caregivers might vary based on the structure of the family or how the caregiver is related to the person with the illness. For instance, Amareshaet al.[4] reported that siblings of persons with schizophrenia have distinct needs compared with other caregivers, such as a need for brief interventions, telephonic services, and support groups, with a higher focus on illness management and functionality. Similarly, Pashapuet al.[5] explored the marital needs of couples where one of the spouses has schizophrenia and found that they specifically face issues in family communication, role functioning, sexual relationship, and legal issues. Philip[6] reported that aging parents of persons with schizophrenia had particular concerns related to future, including the ill member's self-management of the illness and handing over of caregiving after their death. These studies developed and tested psychosocial interventions addressing the unique needs of these caregiver groups.

Another such group, with distinct experiences and needs, is children who have a parent with mental illness. Although they have long been known to be at high risk genetically and environmentally,[7] it is only in recent years that research into preventive mental health for this group has emerged. An encouraging development in this field in India has been the growing movement around perinatal psychiatry, with interventions addressing the parenting needs of mothers with mental illness and their infants.[8],[9] However, studies focusing on older children and adolescents affected by parental mental illness are fewer. Children of varying age groups have differing needs; therefore, the impact of parental mental illness and the opportunities for intervention with them can be diverse.[10]

The rest of this paper reviews the existing research on this topic, both from the global and Indian context. Findings from studies on parents with mental illness and their children are briefly summarized, followed by descriptions of preventive interventions developed for the children. The last section discusses how these findings can inform future research and service development for this population in India.

 Children of Parents With Mental Illness: the Global Context



Globally, 12–45% of mental health service users are reported to be parents.[11] The experiences and needs of families affected by parental mental illness have been predominantly studied from the perspective of the parent with mental illness and their children. These findings are reviewed in the following sections.

 Experiences of Parents With Mental Illness



Studies done around the world with parents with mental illness have described their challenges. Parents have reported that the illness interferes with parenting and have described parenting as stressful and burdensome.[12],[13],[14],[15],[16] A two-way relationship between parental mental health and the parent–child relationship has been proposed, wherein parental psychopathology can strain parent–child relationships and possibly lead the child to distance from the parent emotionally, thereby further disenfranchising the parent, increasing their distress, and impeding recovery.[17]

In addition to the direct impact of the mental illness on parenting, parents have described other circumstances that add to their vulnerability. Mental illness often co-occurs with other psychosocial adversities such as poverty, marital discord and separation, and downward social and economic mobility,[18],[19] thereby increasing the patients' need for support. There is also stigma and discrimination in relation to parenthood experienced by those with mental illness, including being stopped from having children, being seen as unfit parents, being separated from their children, and being blamed for their child's difficulties.[20] Parents have reported that the fear of losing child custody prevents them from seeking treatment, disclosing to professionals that they are parents, and discussing parenting difficulties.[21],[22] The stigma of “failing as a parent” has been described as perhaps greater than the stigma of mental illness itself.[21]

Despite these negative experiences and effects, many parents have also described parenting as a “road to recovery” as it enriches and provides a structure to their lives[23] and motivates them to seek treatment.[24] Therefore, there is a need to expand our understanding of parenting with mental illness. Instead of focusing exclusively on deficits and impairments in parenting, which leads to further marginalization and exclusion,[14] there is a need to pay equal attention to the individual strengths and motivations of parents and also to the structural barriers that increase their vulnerability.[25] They need to be provided with ongoing instrumental, emotional, and social support so that they can be better parents.[26],[27]

 Experiences of Children of Parents With Mental Illness



Studies exploring children's experiences of living with a parent with mental illness have also described both positive and negative aspects. Children have identified concerns such as lack of information, disruptions in the family, having to take up caregiving roles, and lack of support services. Children also have difficulties in managing their emotions and experiences of stigma and social isolation.[28] At the same time, children have also reported positive gains from these experiences, such as becoming more mature and responsible, and they report wanting to be involved in the care of their parent.[29],[30],[31]

Recurring themes in these narratives are the children's need for information and support. Children have talked about the need for education about parental mental illness, improved coping skills, and support from mental health professionals and schools.[32],[33] Many children have reported feeling apprehensive about visiting their parent in the hospital and expressed that the - hospitals need to be “family friendly” and accommodate needs of the children of parents with mental illness, and at the same time acknowledge their caring efforts.[34],[35]

 Interventions for Families Affected by Parental Mental Illness



Based on the needs that have emerged from these studies, several interventions have been developed for families affected by parental mental illness. Some interventions include only the parents or the children, but with a focus on the family, whereas other interventions involve the whole family. Interventions with parents predominantly focus on training in parenting skills[36],[37] or psychoeducation and peer support.[38] Let's Talk about Children[39] is one such psychoeducational intervention that involves 15–45 min discussions with the ill parent and his/her partner, to assess the child's situation and empower the parents to talk to their children about the illness.

Interventions targeted at the children are mostly aimed at providing psychoeducation, peer support and respite, in individual or group formats.[40],[41],[42],[43] Some also provide skills training[44],[45] and resource coordination.[46] Although some of these activities are delivered in a clinic setting, others are designed as after-school workshops,[47],[48] camps,[49],[50] or online interventions,[51],[52] to make them more accessible for children.

A third set of interventions targeting the whole family involve interventions such as psychoeducation; cognitive restructuring; teaching communication skills, problem-solving and parenting strategies; and case-management strategies. One of the earliest and most researched is Beardslee's preventive family intervention or “Family Talk.”[53] This was originally designed for parents with affective disorders and their children aged 8–15 years and involved 6–10 sessions with a clinician. Separate sessions with parents and children focus on gathering history, psychoeducation, and preparation for a joint session. The joint session focuses on initiating and enhancing communication about the illness between the parents and the children. This intervention has been adapted to include other age groups and diagnoses.[39],[54],[55]

Other family interventions entail child-inclusive discussions to generate care plans and discuss parenting issues.[56],[57],[58] Some interventions have used the cognitive-behavioral approach in a single family format[59],[60] or a multi-family group format.[61],[62] Studies also highlight community and home-based interventions-including services that link families with environmental supports and provide access to financial resources and liaison and advocacy services.[63],[64],[65]

A recent systematic review reported that preventive interventions with this population lead to significant improvement in parenting behaviors,[66] and a meta-analysis reported positive effects on the children's behavioral and emotional health, with interventions that jointly addressed parents and children yielding larger effects.[67] However, they also pointed out a lack of high-quality studies and recommended adoption of more rigorous research methods to test the interventions[66],[67],[68]

 Challenges in Working With Families Affected by Parental Mental Illness



Various challenges in working with this population have been identified within adult mental health systems, including the complexity of the issue;[69] a lack of attitude, knowledge, skill and confidence for working on parenting and family issues;[70] a lack of clarity about staff roles; and limited options of referral services.[71]

It has also been suggested that mental health systems often operate from an individual level, problem/deficit-focus approach, where preventive interventions are not given priority. Hence, issues of parenting and children are addressed only if abuse or neglect is identified or if the child develops a diagnosable disorder.[72]

To overcome these challenges, Maybery and Reupert[73] recommend the adoption of family-sensitive policies at the organizational level, coupled with ongoing workforce training. Such a system would set up processes to routinely identify a service user's children, assess the family's parenting and child-related needs, and provide psychoeducation to each family member and have a clear system of referrals. Additionally, the agency would have more specialized family services, such as family therapy, where families with more intensive needs can be referred.

Several interventions have been designed for professionals in adult mental health settings to sensitize and equip them to work with children and families affected by parental mental illness.[74],[75],[76] Other measures include having designated “child representatives”[77] or “child-responsible personnel”[78] in adult mental health settings.

In addition to improvements in adult mental health services, other recommendations include increasing investment in child and adolescent mental health services, creating adequate community support for families, building intersectoral collaborations such as with child-protection agencies, and lobbying governments to recognize this group of vulnerable children.[10]

 Children of Parents With Mental Illness: the Indian Context



There are no large-scale epidemiological studies from India that report the prevalence of parenthood among persons with mental illness, but a few clinic-based studies provides an approximate picture. A study of persons with schizophrenia found that about 49% of them had children,[79] and a study of female inpatients in a psychiatric hospital reported a figure of 66%.[80] Another recent study reported that despite stigmatizing experiences related to marriage and childbirth, 57% of the participants with mental illness were married, and many of them had children.[81]

Studies done in India with children of parents with mental illness have found that they use maladaptive coping strategies[82] and have higher levels of internalizing and externalizing problems.[83],[84] Adult children of parents with mental illness have reported that they had experienced many disruptive experiences in their childhood, such as unstable families, parental discord, and having to discontinue education to go into employment.[85] Many of them, though resilient, reported burden and lack of support[86] and lower levels of psychological well being.[87]

It has been reported that children are negatively affected by poor information about parental illness and inadequate role functioning in the ill parent.[5] Spouses of persons with mental illness have reported concerns about the effects of parental mental illness and the ways to support their children.[88]

Much of this literature focuses on deficits and risks, and there is little published literature in the Indian context about how ill parents perceive their parenting role, how children experience growing up with an ill parent, how families navigate parenting challenges, and what support they need.

 Implications for the Indian Mental Health Setting



Due to the lack of literature from India, our current understanding of these topics rests predominantly on western studies. Although western studies set a precedent for the conceptualization of preventive interventions for children and families with parental mental illness, local studies are needed to contextualize these findings to India—both to the culture of Indian families and to the way Indian mental health services are organized.

Research with family caregivers in India is still predominantly limited to concepts such as stress and burden,[89] and there is a need to shift the focus to understanding their experiences as a whole and to explore themes related to parenting and children. Several characteristics of Indian families, such as rigid hierarchical structures and an emphasis on kinship obligations, might affect the way parents and children relate and communicate with each other.[1],[89] As formal foster care is uncommon in India,[81] some children are likely to be in the informal care of extended family members. These features of the Indian context could alter the experiences of families with parental mental illness.

Additionally, these interventions need to be adapted to suit the way Indian mental health systems are organized and the resources that are available. Research is also needed to identify how other agencies such as child protection systems, schools, and general healthcare settings can play a role in supporting children, parents, and families affected by parental mental illness. The inadequacy of resources is a major barrier in not prioritizing preventive child and family mental health in India.[90] Therefore, in addition to studying outcomes, rigorous studies examining the cost-effectiveness and returns-on-investment of preventive interventions with this population are needed, to support policies and services for this population.[65] In building workforce capacity, training a few specialist professionals who can go on to provide consultations and carry out advocacy and further capacity-building programmes[10] may be an efficient option.

Some ways to increase visibility for this population within adult mental health services would be to routinely assess if service users are parents and if so, to document information such as the children's age and living and parenting arrangements. It would be useful to keep in mind that persons with mental illness and their families might be apprehensive in initiating discussions about parenting and children. Children themselves might have concerns about inheriting the illness from the parent and might feel anxious at the prospect of meeting with mental health professionals. This reiterates the need for professionals to raise these topics in sensitive ways. When children accompany or visit their parent in the hospital, professionals could encourage them to share their experience and concerns and appreciate them for their contributions to the care of the parent. Where appropriate, and when families and children are willing, children could be invited to participate in routine family interventions or referred to specialist child and family psychiatric services.

 Conclusion



Despite a long tradition of involving families in mental healthcare in India, more attention needs to be focused on the diversity among families affected by mental illness. There is a growing understanding of the unique vulnerabilities and needs of children and families affected by parental mental illness. This highlights the need to take forward research in this area and for developing preventive child and family mental health interventions.

Financial support and sponsorship

First author supported by UGC-JRF (No.: 1266/NET.DEC-2012).

Conflicts of interest

There are no conflicts of interest.

References

1Chadda RK, Deb KS. Indian family systems, collectivistic society and psychotherapy. Indian J Psychiatry 2013;55:299-309.
2Avasthi A. Preserve and strengthen family to promote mental health. Indian J Psychiatry 2010;52:113-26.
3Shankar R, Rao K. From Burden to Empowerment: The Journey of Family Caregivers in India. Families and Mental Disorders. Chichester, England: John Wiley & Sons, Ltd.; 2005. p. 259-90.
4Amaresha AC, Joseph B, Agarwal SM, Narayanaswamy JC, Venkatasubramanian G, Muralidhar D, et al. Assessing the needs of siblings of persons with schizophrenia: A qualitative study from India. Asian J Psychiatr 2015;17:16-23.
5Pashapu DR, Hamza A, Chandra PS, Marimuthu A. Qualitative study on the marital needs of couples with a spouse living with schizophrenia in India. International Journal of Research and Scientific Innovation 2014;1:5-11.
6Philip JV. Psychosocial Management of Burden of Ageing Caregivers in Families of Persons with Schizophrenia (Unpublished Doctoral Dissertation). Bangalore: National Institute of Mental Health & Neurosciences; 2015.
7Rutter M, Quinton D. Parental psychiatric disorder: Effects on children. Psychol Med 1984;14:853-80.
8Chandra PS, Desai G, Reddy D, Thippeswamy H, Saraf G. The establishment of a mother-baby inpatient psychiatry unit in India: Adaptation of a Western model to meet local cultural and resource needs. Indian J Psychiatry 2015;57:290-4.
9Reddy PD, Desai G, Hamza A, Karthik S, Ananthanpillai ST, Chandra PS. Enhancing mother infant interactions through video feedback enabled interventions in women with schizophrenia: A single subject research design study. Indian J Psychol Med 2014;36:373-7.
10Brockington I, Chandra P, Dubowitz H, Jones D, Moussa S, Nakku J, et al. WPA guidance on the protection and promotion of mental health in children of persons with severe mental disorders. World Psychiatry 2011;10:93-102.
11Maybery D, Reupert AE. The number of parents who are patients attending adult psychiatric services. Curr Opin Psychiatry 2018;31:358-62.
12Diaz-Caneja A, Johnson S. The views and experiences of severely mentally ill mothers--A qualitative study. Soc Psychiatry Psychiatr Epidemiol 2004;39:472-82.
13Wilson L, Crowe M. Parenting with a diagnosis bipolar disorder. J Adv Nurs 2009;65:877-84.
14Montgomery P. Mothers with a serious mental illness: A critical review of the literature. Arch Psychiatr Nurs 2005;19:226-35.
15Nicholson J, Sweeney EM, Geller JL. Focus on women: Mothers with mental illness: I. The competing demands of parenting and living with mental illness. Psychiatr Serv 1998;49:635-42.
16Oyserman D, Bybee D, Mowbray C, Kahng SK. Parenting self-construals of mothers with a serious mental illness: Efficacy, burden, and personal growth. J Appl Soc Psychol 2004;34:2503-23.
17Murphy G, Peters K, Wilkes L, Jackson D. A dynamic cycle of familial mental illness. Issues Ment Health Nurs 2014;35:948-53.
18Wade TJ, Pevalin DJ. Marital transitions and mental health. J Health Soc Behav 2004;45:155-70.
19Bassani DG, Padoin CV, Veldhuizen S. Counting children at risk. Soc Psychiatry Psychiatr Epidemiol 2008;43:927-35.
20Jeffery D, Clement S, Corker E, Howard LM, Murray J, Thornicroft G. Discrimination in relation to parenthood reported by community psychiatric service users in the UK: A framework analysis. BMC Psychiatry 2013;13:120.
21Niholson J. Use of child custody as leverage to improve treatment adherence. Psychiatr Serv 2005;56:357-8.
22Reupert A, Maybery D. Fathers' experience of parenting with a mental illness. Families in Society 2009;90:61-8.
23van der Ende PC, van Busschbach JT, Nicholson J, Korevaar EL, van Weeghel J. Strategies for parenting by mothers and fathers with a mental illness. J Psychiatr Ment Health Nurs 2016;23:86-97.
24Jones M, Pietila I, Joronen K, Simpson W, Gray S, Kunonen M. Parents with mental illness - a qualitative study of identities and experiences with support services. J Psychiatr Ment Health Nurs 2016;23:471-8.
25Olsen R, Clarke H. Parenting and Disability: Disabled Parents' Experiences of Raising Children. Bristol (UK): The Policy Press; 2003.
26Darlington Y, Feeney JA. Clients' and professionals' experiences of traversing mental health and child protection systems: Implications for practice. Families in Society 2009;90:382-9.
27David DH, Styron T, Davidson L. Supported parenting to meet the needs and concerns of mothers with severe mental illness. Am J Psychiatr Rehabil 2011;14:137-53.
28Gladstone B, Boydell K, Seeman M, McKeever P. Children's experiences of parental mental illness: A literature review. Early Interv Psychiatry 2011;5:271-89.
29Ostman M. Interviews with children of persons with a severe mental illness: Investigating their everyday situation. Nord J Psychiatry 2008;62:354-9.
30Griffiths J, Norris E, Stallard P, Matthews S. Living with parents with obsessive-compulsive disorder: Children's lives and experiences. Psychol Psychother 2012;85:68-82.
31Van Parys H, Rober P. Trying to comfort the parent: A qualitative study of children dealing with parental depression. J Marital Fam Ther 2013;39:330-45.
32Bee P, Berzins K, Calam R, Pryjmachuk S, Abel KM. Defining quality of life in the children of parents with severe mental illness: A preliminary stakeholder-led model. PLoS One 2013;8:e73739.
33Grové C, Reupert A, Maybery D. The perspectives of young people of parents with a mental illness regarding preferred interventions and supports. J Child Fam Stud 2016;25:3056-65.
34O'brien L, Anand M, Brady P, Gillies D. Children visiting parents in inpatient psychiatric facilities: Perspectives of parents, carers, and children. Int J Ment Health Nurs 2011;20:137-43.
35Fudge E, Mason P. Consulting with young people about service guidelines relating to parental mental illness. Australian e-journal for the Advancement of Mental Health 2004;3:50-8.
36Phelan RF, Howe DJ, Cashman EL, Batchelor SH. Enhancing parenting skills for parents with mental illness: The mental health positive parenting program. Med J Aust 2013;199 (3 Suppl):S30-3.
37Sanford M, Byrne C, Williams S, Atley S, Miller J, Allin H. A pilot study of a parent-education group for families affected by depression. Can J Psychiatry 2003;48:78-86.
38Kaplan K, Solomon P, Salzer MS, Brusilovskiy E. Assessing an Internet-based parenting intervention for mothers with a serious mental illness: A randomized controlled trial. Psychiatr Rehabil J 2014;37:222.
39Solantaus T, Paavonen EJ, Toikka S, Punamaki RL. Preventive interventions in families with parental depression: Children's psychosocial symptoms and prosocial behaviour. Eur Child Adolesc Psychiatry 2010;19:883-92.
40Hayman FM. Kids with confidence: A program for adolescents living in families affected by mental illness. Aust J Rural Health 2009;17:268-72.
41Hargreaves J, O'Brien M, Bond L, Forer D, Basile A, Davies L. Paying attention to self (PATS): An evaluation of the PATS program for young people who have a parent with a mental illness. Melbourne: Centre for Adolescent Health, 2005.
42Orel NA, Groves PA, Shannon L. Positive connections: A programme for children who have a parent with a mental illness. Child Fam Soc Work 2003;8:113-22.
43Riebschleger J, Tableman B, Rudder D, Onaga E, Whalen P. Early outcomes of a pilot psychoeducation group intervention for children of a parent with a psychiatric illness. Psychiatr Rehabil J 2009;33:133.
44Pitman E, Matthey S. The SMILES program: A group program for children with mentally ill parents or siblings. Am J Orthopsychiatry 2004;74:383-8.
45Fraser E, Pakenham KI. Evaluation of a resilience-based intervention for children of parents with mental illness. Aust N Z J Psychiatry 2008;42:1041-50.
46Finkelstein N, Rechberger E, Russell LA, VanDeMark NR, Noether CD, O'Keefe M, et al. Building resilience in children of mothers who have co-occurring disorders and histories of violence: Intervention model and implementation issues. J Behav Health Serv Res 2005;32:141-54.
47Cooklin A. Children as carers of parents with mental illness. Psychiatry 2006;5:32-5.
48Wolpert M, Hoffman J, Martin A, Fagin L, Cooklin A. An exploration of the experience of attending the Kidstime programme for children with parents with enduring mental health issues: Parents' and young people's views. Clin Child Psychol Psychiatry 2014;20:406-18.
49Grové C, Reupert A, Maybery D. Peer connections as an intervention with children of families where a parent has a mental illness: Moving towards an understanding of the processes of change. Child Youth Serv Rev 2015;48(Supplement C):177-85.
50Foster K, McPhee I, Fethney J, McCloughen A. Outcomes of the ON FIRE peer support programme for children and adolescents in families with mental health problems. Child Fam Soc Work 2016;21:295-306.
51Woolderink M, Bindels JA, Evers SM, Paulus AT, van Asselt AD, van Schayck OC. An online health prevention intervention for youth with addicted or mentally ill parents: Experiences and perspectives of participants and providers from a randomized controlled trial. J Med Internet Res 2015;17:e274.
52Drost LM, Cuijpers P, Schippers GM. Developing an interactive website for adolescents with a mentally ill family member. Clin Child Psychol Psychiatry 2011;16:351-64.
53Beardslee WR, Gladstone TR, Wright EJ, Cooper AB. A family-based approach to the prevention of depressive symptoms in children at risk: Evidence of parental and child change. Pediatrics 2003;112:e119-31.
54Pihkala H, Cederström A, Sandlund M. Beardslee's preventive family intervention for children of mentally ill parents: A Swedish National Survey. International Journal of Mental Health Promotion 2010;12:29-38.
55Christiansen H, Anding J, Schrott B, Rohrle B. Children of mentally ill parents-a pilot study of a group intervention program. Front Psychol 2015;6:1494.
56Cowling V, Garrett M. A child-inclusive family intervention in a community adult mental health service. Australian and New Zealand Journal of Family Therapy 2012;33:101-13.
57Maybery DJ, Goodyear MJ, Reupert AE, Harkness MK. Goal setting within family care planning: Families with complex needs. Med J Aust 2013;199:37-9.
58Nicholson J, Albert K, Gershenson B, Williams V, Biebel K. Family options for parents with mental illnesses: A developmental, mixed methods pilot study. Psychiatr Rehabil J 2009;33:106-14.
59Ginsburg GS. The child anxiety prevention study: Intervention model and primary outcomes. J Consult Clin Psychol 2009;77:580-7.
60Ginsburg GS, Drake KL, Tein JY, Teetsel R, Riddle MA. Preventing onset of anxiety disorders in offspring of anxious parents: A randomized controlled trial of a family-based intervention. Am J Psychiatry 2015;172:1207-14.
61Compas BE, Forehand R, Thigpen JC, Keller G, Hardcastle EJ, Cole DA, et al. Family group cognitive-behavioral preventive intervention for families of depressed parents: 18- and 24-month outcomes. J Consult Clin Psychol 2011;79:488-99.
62Valdez CR, Mills CL, Barrueco S, Leis J, Riley AW. A pilot study of a family-focused intervention for children and families affected by maternal depression. J Fam Ther 2011;33:3-19.
63Kessler ML, Ackerson BJ. Wraparound services: An effective intervention for families impacted by severe mental illness. J Fam Soc Work. 2005;8:29-45.
64Brunette MF, Richardson F, White L, Bemis G, Eelkema RE. Integrated family treatment for parents with severe psychiatric disabilities. Psychiatr Rehabil J 2004;28:177-80.
65Wansink HJ, Drost R, Paulus AT, Ruwaard D, Hosman CM, Janssens J, et al. Cost-effectiveness of preventive case management for parents with a mental illness: A randomized controlled trial from three economic perspectives. BMC Health Serv Res 2016;16:228.
66Bee P, Bower P, Byford S, Churchill R, Calam R, Stallard P, et al. The clinical effectiveness, cost-effectiveness and acceptability of community-based interventions aimed at improving or maintaining quality of life in children of parents with serious mental illness: A systematic review. Health Technol Assess 2014;18:1-250.
67Thanhäuser M, Lemmer G, de Girolamo G, Christiansen H. Do preventive interventions for children of mentally ill parents work? Results of a systematic review and meta-analysis. Curr Opin Psychiatry 2017;30:283-99.
68Reupert AE, Cuff R, Drost LM, Foster K, van Doesum KTM, van Santvoort F. Intervention programs for children whose parents have a mental illness: A review. Med J Aust 2012;196:18.
69Coates D, Howe D. Working with families who experience parental mental health and/or drug and alcohol problems in the context of child protection concerns: Recommendations for service improvement. Australian and New Zealand Journal of Family Therapy 2015;36:325-41.
70Maybery D, Goodyear M, O'Hanlon B, Cuff R, Reupert A. Profession differences in family focused practice in the adult mental health system. Fam Process 2014;53:608-17.
71Pfeiffenberger AS, D'Souza AJ, Huthwaite MA, Romans SE. The well-being of children of parents with a mental illness: The responsiveness of crisis mental health services in Wellington, New Zealand. Child Fam Soc Work 2016;21:600-7.
72Ackerson BJ. Parents with serious and persistent mental illness: Issues in assessment and services. Soc Work 2003;48:187-94.
73Maybery D, Reupert A. Parental mental illness: A review of barriers and issues for working with families and children. J Psychiatr Ment Health Nurs 2009;16:784-91.
74Toikka S, Solantaus T. The effective family programme II: Clinicians' experiences of training in promotive and preventative child mental health methods. International Journal of Mental Health Promotion 2006;8:4-10.
75Tchernegovski P, Reupert A, Maybery D. “Let's Talk about Children”: A pilot evaluation of an e-learning resource for mental health clinicians. Clin Psychol (Aust Psychol Soc) 2015;19:49-58.
76Goodyear M, Obradovic A, Allchin B, Cuff R, McCormick F, Cosgriff C. Building capacity for cross-sectorial approaches to the care of families where a parent has a mental illness. Adv Ment Health 2015;13:153-64.
77Ostman M, Afzelius M. Children's representatives in psychiatric services: What is the outcome? Int J Soc Psychiatry 2011;57:144-52.
78Lauritzen C, Reedtz C. Child responsible personnel in adult mental health services. Int J Ment Health Syst 2016;10:64.
79Thara R, Tirupati S. Marriage and gender in schizophrenia. Indian J Psychiatry 1997;39:64-9.
80Chandra PS, Carey MP, Carey KB, Shalinianant A, Thomas T. Sexual coercion and abuse among women with a severe mental illness in India: An exploratory investigation. Compr Psychiatry 2003;44:205-12.
81Loganathan S, Murthy RS. Living with schizophrenia in India: Gender perspectives. Transcult Psychiatry 2011;48:569-84.
82George S, Shaiju B, Sharma V. Problems faced and coping strategies used by adolescents with mentally ill parents in Delhi. Nurs J India 2012;103:183-7.
83Bhat AS, Srinivasan K. Psychopathology in the adolescent offspring of parents with panic disorder and depression. J Indian Assoc Child Adolesc Ment Health 2006;2:100-7.
84Malhotra M, Kumar D, Verma R. Effect of psychosocial environment in children having mother with schizophrenia. Psychiatry Res 2015;226:418-24.
85Manjula M, Raguram A. Self-concept in adult children of schizophrenic parents: An exploratory study. Int J Soc Psychiatry 2009;55:471-9.
86Herbert HS, Manjula M, Philip M. Growing up with a parent having schizophrenia: Experiences and resilience in the offsprings. Indian J Psychol Med 2013;35:148-53.
87Munivenkatappa M, Raguram A. Experiences of stigma and psychological well being among adult children of parents with schizophrenia. AP J Psychol Med 2014;15:43-9.
88Ballal D, Navaneetham J. Talking to children about parental mental illness: The experiences of well parents. Int J Soc Psychiatry 2018;64:367-73.
89Chakrabarti S. Research on family caregiving for mental illness in India and its impact on clinical practice: Are we doing enough to help families?. Indian Journal of Social Psychiatry 2016;32:19.
90Bhargava R, Sahu A, Bhattacharya D. Prevention for child and adolescent psychiatry in low-resource settings. Indian J Soc Psychiatry 2017;33:123-8.