Community preventive interventions for children of parents with serious mental illness: a commentary on the evidence base

Abstract

Improving the lives of children of parents with serious mental illnesses (SMI) such as schizophrenia, major depression and bipolar disorder is of urgent political and public health concern. Parental SMI is associated with increased risk of multiple adverse child outcomes including poorer short-term mental and physical health, behavioural, social and educational difficulties, maltreatment and neglect (Goodman et al., 2011; Royal College of Psychiatrists [RCPsych], 2011). Longer term outcomes can extend into adulthood and include increased risk of psychiatric morbidity, socio-occupational dysfunction, alcohol or substance misuse and premature death (Goodman et al., 2011; RCPsych, 2011; Weissman, Warner, Wickramaratne, Moreau, & Olfson, 1997). This commentary discusses the existing evidence base for community-based interventions in maintaining or improving health and well-being in the children of parents with SMI, based on the findings of a recent systematic review.National initiatives such as the Australian children of parents with mental illness (COPMI) programme aim to promote better mental health outcomes for the COPMI. The rationale for such initiatives is attracting international support, with contemporary health and social-care policies in countries such as the UK similarly asking for enhanced service provision and family support (Diggins, 2011). The key challenge we are left with is in knowing when and how best to intervene. With increasing emphasis on evidence-based practice, there is a pressing need to demonstrate the clinical effectiveness and cost-effectiveness of interventions for children and families living with parental mental illness.A recent systematic review, funded by the UK National Institute for Health Research, has evaluated the international evidence base for the clinical and cost-effectiveness of community-based interventions for enhancing or maintaining quality of life (QoL) in children living with parents with serious mental illness (Bee et al., 2014). This commissioned review is the largest and most comprehensive review of the international evidence for preventative interventions for families living with SMI to date, and the first and only review focussed on maintaining children's QoL.Our review confirms that the existing evidence for community interventions to enhance the QoL of children of parents with SMI is severely lacking and, in its current form, cannot provide an adequate rationale on which to base practice or service development. Despite thorough and comprehensive searches, we were only able to identify three randomized controlled trials, all conducted in the USA more than two decades previously. All three trials evaluated interventions for maternal psychosis and were heavily targeted towards group-based models seeking to enhance parenting behaviours in the mothers of children aged less than 12 years old. No validated measures of children's QoL or emotional well-being were reported and secondary outcomes were focused on observer ratings of child behaviour and cognitive function. The relevance of these data to current healthcare systems is unclear. Service configuration models and the interface between adult psychiatric services, children's services and social care will vary considerably, both between countries and over time. Equally, children's own QoL judgements are likely to be influenced by the cultural and temporal contexts in which they occur. Doubt therefore exists as to the generalizability of this evidence to contemporary children living with serious parental mental illness.In our review, contemporary evidence of the effectiveness of community interventions to enhance life quality in the children of parents with severe mental illness was limited to a small number of non-randomized studies, traditionally considered lower quality evidence than well-conducted randomized trials capable of demonstrating cause and effect. Four non-randomized trials were eligible for inclusion in our review, three of which were Australian studies published within the last 4 years (i. …