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.
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.
An estimated 50% of North American women suffering from schizophrenia are parents—a percentage identical to that of the general population. A recent community survey in Great Britain suggested that the percentage of women with a psychotic illness who are mothers is as high as 63%.1 This proportion may be growing because psychotic illness is now treated in the community rather than in institutions, treatment outcomes are improving, and current antipsychotic medications no longer raise prolactin levels2 and 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 contraception, and planning responsible parenthood (Table 1). By ensuring safe pregnancies and deliveries and preventing postpartum psychoses, mental health problems in the children 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 suffer from schizophrenia frequently experience 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 contributing to parenting difficulties.
Consequent to their illness, women with schizophrenia abuse alcohol and other substances more than women in the general population. They may continue to do this during pregnancy. They are often single mothers who are economically 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 obtaining 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 isolation and poverty, mothers with schizophrenia give birth to children who may inherit genes for schizophrenia. This can lead to developmental delays in the child and increased parenting difficulty. 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 vulnerability to schizophrenia. About half of the children of women with schizophrenia are known to be born prior to the mother’s diagnosis.5 This 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 preparedness for parenthood, about half of the pregnancies in women with schizophrenia 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 pregnancies are terminated at the mother’s initiative.5 Relatively 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 multiple problems they encounter.6-8
Working in a clinic for women with psychosis9 has allowed a better understanding of the burdens of parenthood in this population, the deficiencies in mothering reported in the schizophrenia literature, the potential risks to children,10 and 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 households. They were asked about their experiences with motherhood and psychosis, 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 report 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 colleagues17 used 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 members. Results indicated that relationships with family were complicated, sometimes supportive, sometimes intrusive, and often perceived as negative. The major themes that emerged from focus groups with mentally ill mothers conducted by Bassett and colleagues18 in Australia were the traumas of loss of custody, hospitalization, social isolation, and stigma. Single parenthood was a significant theme. These mothers identified the need for substitute care, better access to community services, consistency in care provision, and improved relationships 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 relationships.14 They understood that antipsychotic drugs could increase parenting problems and that there was a risk associated with taking them during pregnancy, but they were afraid to stop treatment. They reported personal benefits of being mothers (eg, love, purpose, identity, support), but these benefits were offset by stress, exhaustion, poverty, fear of losing their children, and fear that their children may develop schizophrenia. These mothers relayed feelings of enduring grief and anger following the loss of children to foster care or adoption. They expressed needs for support, information, and therapeutic programs that include social activities, substance abuse counseling, relationship and assertiveness 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 colleagues19 asked 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.19 Joseph and colleagues20 administered a questionnaire to 32 women with schizophrenia. Sixty-one percent turned out to be mothers. While 20% of the mothers had retained full custody, only 12% were actually the primary caregivers. Hearle and colleagues21 reported that 59% of the 110 women in their clinic 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 Jacobsen22 found that significantly more mothers with schizophrenia than controls from similar socioeconomic and marital backgrounds had children in foster care (49% versus 2%) and significantly 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 schizophrenia and related disorders who are in treatment have lost custody of their children at some point, producing discontinuities of upbringing for the children and intense distress for the mothers.
In the community study, a comparatively 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 samples. The reasons for the discrepancy are that the factors that mitigate against becoming a clinic client (higher socioeconomic bracket, intact marriage, supportive family, absence of substance abuse, absence of aggressive behavior) are the same factors that prevent children’s apprehension by child protecion agencies. 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 parenting assessments requested by child protection agencies. Of all psychiatric diagnoses, schizophrenia is perhaps most associated with low mother-infant interaction scores on assessment scales designed to predict healthy development in neonates.23 Using the Global Rating Scales of Mother-Infant Interaction applied to videotaped interactions of mothers and 4-month old infants, mothers with schizophrenia were found to be more remote, silent, verbally and behaviorally intrusive, self-absorbed, flaccid, insensitive, and unresponsive than mothers in the contrast affective disorders group.24 Their infants were more avoidant and the mother-child interaction appeared less satisfying than that of the contrast group.24 Another recent study has underscored the impact of the negative symptoms of schizophrenia on mother-infant interaction.25 Antipsychotic medications may be contributory here.
Early parenting assessments are understandable from the perspective of child protection because adoption decisions are best made during infancy. However, evaluations carried out during the postpartum period put biological mothers at a disadvantage because all psychiatric syndromes, 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 genetically-transmitted schizophrenia. Such children will benefit from extra stimulation and an enriched environment, but this does not necessitate taking the child away. Extras, such as day care centers and holiday camps, can be provided while keeping the child in the maternal home.
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 schizophrenia 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 diagnosed with schizophrenia.26
A 3-year study testing young children of black, low income, single mothers, came to a somewhat different conclusion.27 Mothers were diagnosed with either schizophrenia, depression, or no mental illness. In most domains of functioning, the children of the mothers with schizophrenia had the most problems. The child-rearing environment of the children of mothers with schizophrenia was characterized 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 children than were well mothers. The following protective factors were identified: 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.27 In a later report on this study, the authors stated that parenting practices, not mother’s diagnosis, were the key to healthy child development.28
In a more recent study, Yoshida and colleagues29 found that infants of mothers 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 schizophrenic 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 schizophrenia, and another 4.6% developed a related illness (versus 0.9%).30 The rate of mood disorder was the same in the both groups. These findings are expected from what we know about the genetic transmission of schizophrenia.
Twenty-five of the Copenhagen children 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 inherited more severe psychopathology, this finding underscores the fact that rearing by a mother with schizophrenia 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 schizophrenia frequently do not avail themselves of prenatal care.32 Their risk for premature delivery and low birth weight is 50% greater than that of the general population.33,34 Adequate prenatal care can, at least theoretically, reduce the incidence of schizophrenia in these children.35 A comprehensive service should include diagnostic and treatment components; emergency, inpatient, and outpatient services; outreach to parents and children; linkages with schools, camps, extended families, child protection, and legal services; and obstetric and pediatric facilities. Among the required resources are case management outreach teams; neuropsychological assessors; parenting capacity assessors; therapeutic group leaders; child, adult, and family therapists; and pharmacotherapists. Interventions should include symptom management, parenting classes, addiction treatments, family planning education, therapeutic nurseries, support and information groups, occupational and vocational help, homemaking 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 systems to work cooperatively and preventively toward resolving opposing perspectives and keeping families together whenever possible.36-38
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 assesessment 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 crucial services that the primary care physician is best positioned to offer.
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