Communicating to children about parental depression

Depression accounts for more disability-adjusted life years (DALYs) throughout the world than any other condition. This study is based in South Africa which has a higher prevalence of depression than many other LMICs, with a third of the population experiencing a mental health disorder in their lifetime. Notably, 68% of women and 57% of men who experience mental health problems are parents. Symptoms of common mental disorders can interfere with relationships and disrupt family functioning; depression is significantly associated with negative, disengaged and sometimes hostile parenting. Parental depression and anxiety increase the risk of attachment, emotional and behavioural difficulties in children, with long-term implications for interpersonal relationship difficulties, educational and human capital outcomes.

The study, based in rural South Africa, explored the barriers and facilitators to communicating with children about parental mental illness through interviews and focus groups. Initial analyses have found that facilitators include the importance of the “whole family” in communication (including reliable elders/ grandparents/ aunties); past experience with group therapy and group psychoeducation and its suitability in this context; involving (recovering) mental health service-users in patient education and particularly in addressing stigma. In addition, the physical and social needs of the children of parents with mental illness were paramount as well as their psychological needs e.g., such as having a reliable alternate caregiver, food, education, social support.

Surprisingly there are no evidence-based guidelines for Healthcare Workers (HCWs) to support parents on how to communicate effectively with their children about mental illness. The data from this study will lead to the development of a set of developmentally and culturally appropriate guidelines for HCWs (ranging from community health workers to hospital consultants). Through the experiences and knowledge of the study participants the challenges of communicating with children about parental mental illness will also be identified to ensure that the guidelines are viable and of practical use to frontline HCWs in LMICs. A central theme emerging from the study is that depression and anxiety are grossly under-diagnosed and patients only present when the depression and anxiety are severe.

The onset of the COVID-19 pandemic and its accompanying lockdown has wrought unprecedented challenges including considerable uncertainty about the future, loss of income and opportunities, school-closures. These are significant psychosocial stressors for parents and families so children are exposed to even higher levels of distress, anxiety and depression in the adults around them, whilst simultaneously having their usual coping strategies and social infrastructure disrupted (Danese et al., 2020). Furthermore, parents may avoid talking about difficult feelings and events, and the communication needs of children witnessing distress amongst their caregivers may be overlooked (Dalton et al., 2020). As a consequence of this increase in psychosocial stressors to the community we broadened the scope of our research to include communication with children about parental depression, anxiety and psychosocial distress (as opposed to depression alone). In addition, owing to the need to ensure the wellbeing of HCWs through appropriate social/ physical distancing we conducted an initial series of individual in-depth interviews prior to any focus group discussions. 

All of the study activities have taken place in the South African site facilitated by the team permanently based at the Agincourt site (with oversight and help from the team based in the UK who could not travel to the site due to the pandemic). Therefore, ethical approval had to be granted not only by the University of Witwatersrand but provincial approval from the Provincial Department of Health Research in Mpumalanga. This has meant that HCWs from Agincourt CHC, Belfast Clinic (Bushbuckridge), Cunningmore Clinic, Justica Clinic, Kildare Clinic, Lillydale clinic, Rolle Clinic, Thulamashe CHC, Tintswalo and Mapulanenh Hospitals were invited to take part in the study and have ranged from a doctor in charge of the psychiatry unit at Tintswalo which serves 700,000 people to an occupational therapist from a small clinic.  As part of this process all of the managers of these health facilities were contacted and co-developed the advertising and recruitment plan for participants. The final set of guidelines will also be co-designed and developed with the study participants.

Parental mental illness has a major impact on future generations including educational and life opportunities. This is magnified in economically and socially disadvantaged communities in low-middle income countries (LMICs) such as South Africa. The study outputs have highlighted that HCWs acknowledge that: 

• parental mental illness is formally under diagnosed but is actually very common; 
• the long-term and serious effects it has on children; children ‘pick up’ that something is wrong with their parent and are confused, upset and fearful; 
• it is important to talk to children and families as a whole about the illness; 
• there are no resources available to help with communication with families. This study will increase HCW’s understanding of how they can facilitate these sensitive conversations and provide them with culturally appropriate and practical guidelines to help them structure this communication. Not only will this increase capacity of the HCWs, but help to improve the long term health of families.

This project was funded by the University's GCRF QR fund.